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Based on observations and interviews, the facility failed to ensure disposable and sterile supply inventory was monitored to ensure items were not retained past the expiration date to prevent their being used in patient care.

This failure created the potential for supplies and equipment to lose both sterility and effectiveness, leading to the inability to emergently treat patients timely and effectively.

FINDINGS

REFERENCE

According to the manufacturer's instructions for the Heart Start Home Defibrillator, check supplies and accessories for damage and expiration dating. Replace any used, damaged or expired items.

According to the manufacturer's instructions Stat-Padz multi-function, Pro-Padz Radiolucent, dried out gel can lead to skin burning.

According to the AED Universe ZOLL AED Resources, Frequently Ask Questions about ZOLL AED plus Defibrillators, check the expiration date of your AED pads (Adult and Pediatric). If the pads are beyond the expiration date they should be replaced. http://www.aeduniverse.com/ZOLL_AED_Plus_Resources_s/34.htm

According to a manufacture's letter provided by the facility, based on test results Kendall Diagnostic Electrodes are designed to stay fresh up to 45 days out of package.

According to the manufacturer's instructions for the Evacuated Blood Collection System, do not use tubes after their expiration date. Tubes expire on the last day of the month and year indicated.

1. The facility failed to identify and remove expired disposable/sterile supplies from the following areas: Cardiopulmonary room, Respiratory room, Laboratory and Central Supply.

a) On 01/25/16 at 1:04 p.m., a tour of the cardiopulmonary room was conducted with Chief Nursing Officer (CNO #9) and the Director of Facilities (Director #10). During the tour, inspection of the cardiopulmonary crash cart revealed a set of Zoll Stat-Padz Adult Electrodes with expiration date with 09/07/15. A tour of the respiratory room revealed 10 packs of 5400 Diagnostic Tab Electrodes with an expiration date of 10/2015. CNO #9 stated expired supplies were not appropriate for patient use.

b) On 01/25/16 at 2:30 p.m., a tour of the Laboratory (Lab) was conducted with Lab Manager (Employee #2). During the tour, inspection of the Laboratory's blood draw area revealed 13 yellow top test tubes with the expiration date of 08/2015. Employee #2 stated staff was supposed to go through and check for expired supplies, and staff was supposed to restock supplies with the older supply in front of the newer supply.

c) On 01/25/16 at 3:46 p.m., a tour of the Central Supply was conducted with CNO #9 and the Director #10. One of the shelves revealed six packages with Kendall foam electrode pads with the expiration date of 07/15, and two adult Phillips AED pads with a used by date of 01/00/16. Another shelf revealed ten #10 argyle trocar thoracic catheters, eleven # 12 argyle trocar thoracic catheters, four #6 argyle trocar thoracic catheters, seven #24 argyle trocar thoracic catheters, ten #28 argyle trocar thoracic catheters and two #32 argyle trocar thoracic catheters with no expiration date. An interview with CNO #9 and Director #10 was conducted and they stated the argyle trocar thoracic catheters were obsolete and were not to be used.

d) On 01/26/16 at 12:21 p.m., an interview was conducted with Director of Revenue Cycle (Director #8) who stated medical staff were supposed to go through and check for expired supplies. S/he also stated when staff did their PAR re-supplying on the units they were supposed to check for outdates and remove them. Director #8 also stated staff was supposed to follow the first in first out process meaning new products are placed behind old the old products, and the electrocardiogram (EKG) Kendall pads just got missed.

Based on observations, interviews, and document reviews, the facility failed to ensure the physical safety of patients and the operating rooms by not routinely monitoring temperature and humidity levels and addressing issues when these levels were out of the facility's defined range.

This failure created the potential for excessive humidity causing damp or moist supplies resulting in microbial growth. This failure also created the potential for too low humidity resulting in an increased risk of infection or fire.

FINDINGS:

POLICY

According to policy, Temperature and Humidity in the Operating Rooms (OR), temperatures in the OR will be maintained between 62 and 73 degrees Fahrenheit. Humidity will be maintained at a minimum of 20% relative humidity.


1. The facility failed to ensure the temperature and humidity levels for OR rooms #1 and #2 were within the acceptable ranges. The facility's OR Temperature and Humidity Record log had an acceptable range identified as of 20%-60%.

a) On 01/26/15 at 12:00 p.m., a tour of the facility was conducted with the OR Nurse (Employee #3). Review of the Temperature and Humidity Records in the ORs revealed incomplete documentation and out of range temperature and humidity levels during the months of November 2015 through January 2016. Employee #3 stated s/he was unaware of all the discrepancies noted on the Temperature and Humidity Records. S/he further stated staff was expected to notify maintenance when the humidity levels were above or below the acceptable ranges so maintenance could address the issue. S/he stated staff was to log the reading from the portable battery operated humidity box and not the white humidity wall unit.

b) Review of the Temperature and Humidity Record for OR #1 and OR #2 revealed the following discrepancies:
November 17, 2015 and November 23, 2015 were missing temperature and humidity readings.
December 3, 2015 and December 4, 2015 were missing temperature and humidity readings.
January 13, 2016 was missing a temperature and humidity reading.

Review of the Temperature and Humidity Record for OR #1 revealed the following discrepancies:
In November 2015, 15 of 17 documented temperature ranges were recorded between 53-59 degrees Fahrenheit.
In December 2015, 14 of 17 documented temperature ranges were recorded between 47-59 degrees Fahrenheit.
In January 2016, 14 of 16 documented temperature ranges were recorded between 57-60 degrees Fahrenheit.

Review of the Temperature and Humidity Record for OR #2 revealed the following discrepancies:
On November 2, 2015 there was a documented temperature of 76 degrees Fahrenheit.

The log contained the following out of range humidity readings:
In November 2015, 7 of 17 documented readings, were at 19% relative humidity.
In December 2015, 7 of 17 documented readings, were at 19% relative humidity.
In January 2016, 8 of 16 documented readings, were at 19% relative humidity.


c) On 01/26/16 at 2:05 p.m., an interview was conducted with a Director of Facilities (Director #10), who stated staff in the OR were responsible for logging the temperature and humidity in each OR on a daily basis. Director #10 stated staff were suppose to notify maintenance of any abnormal temperature and humidity readings. S/he stated staff should be logging the humidity from the white humidity unit on the wall and not the portable battery operated humidity box, which conflicts with what Employee #3 previously stated.

d) On 01/26/16 at 2:05 p.m., an interview was conducted with a Director of Surgery (Director #7), who stated staff are supposed to call maintenance who will then come and adjust the temperature or humidity in the room. S/he stated staff should not be using the battery operated temperature and humidity reader, they should be using the white box on the wall because it was connected to the OR. This conflicts with what Employee #3 previously stated. Director #7 confirmed the logs were out of range.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §485.635, PROVISION OF SERVICES, was out of compliance.

C-0278 - Standard: A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain infection control processes in the areas of food storage, disinfection of surgical instruments, hand hygiene and cleaning of medical equipment. This failure created the potential for patients to experience illness due to exposure to food borne pathogens.

C-0280 - Standard: These policies are reviewed at least annually by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. The facility failed to review policies which govern patient care practices at least annually. This failure created the potential for patients to receive inconsistent levels of care and created the potential for an unsafe setting.

Based on observations, interviews and document review the facility failed to maintain appropriate infection control processes in the areas of food storage, disinfection of surgical instruments, hand hygiene and cleaning of medical equipment.

This failure created the potential for patients to experience illness due to exposure to food borne pathogens if unlabeled food or expired/unsafe food was served to patients. Additionally, this failure created the potential for patients to be at risk for health care acquired infections.

FINDINGS

POLICY

According to the policy Decontamination-Receiving and Handling, the person assigned to the decontamination area will render all items returned to Central Service free of pathogens making it safe for handling by facility personnel and safe for patient use.

According to the policy Equipment Management and Cleaning, all staff will receive training on the use and cleaning of all medical equipment they will be expected to use. All patient care equipment will be cleaned and disinfected according to the Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004, between every patient and when visibly soiled. Such equipment includes patient bedside equipment and work stations on wheels (WOW).

According to the policy Standard Precautions, gloves should be changed between tasks on the patient after contact with any material that may contain microorganisms. Hands are to be washed after removing gloves and do not take the place of hand hygiene.

According to the policy Infection Control - Hand-Hygiene is completed to reduce the number of viable microorganisms on the hands and to prevent the transmission and incidence of health care associated infections (HAI). Hands not visibly soiled may be decontaminated with an alcohol-based hand rub. Hands should be decontaminated before and after contact with a patient's intact skin, before donning and after removal of gloves, and after contact with inanimate objects in the immediate vicinity of the patient, including medical equipment.

REFERENCE

According to the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), Part II.D., (pg. 49), Hand Hygiene, improved hand hygiene practices have been linked to a sustained lowering of the incidence of infection. Use of alcohol-based products, which do not require the use of water, have been approved for hand disinfection and are preferred for use in light of their superior microbial activity and convenience when hands are not visibly soiled.

Furthermore, Part II.E.1., (pgs. 50-51), Gloves can protect patients from exposure to infectious material that may be carried on hands. Gloves should be changed if the patient interaction also involves touching portable computer keyboards or other mobile equipment used in the care of multiple patients. Hand hygiene following glove removal prevents the transmission of potentially infectious material that may have penetrated unrecognized tears or contaminate the hands during glove removal.

According to Part II.I., (pg. 60), Environmental measures, the cleaning and disinfection of frequently touched surfaces in patient care areas are part of Standard Precautions.

According to the Association of periOperative Registered Nurses (AORN) Preoperative Standards and Recommended Practices (2015 ed.), Recommendation VIIII.g.- whenever multi-dose medication vials are used personnel administering medications should use safe medication practices including: disinfection of the rubber septum with alcohol before each entry; a new needle and new syringe should be used every time the multi-dose vial is accessed. The risk of cross contamination is increased when safe medication practices are not adhered to during the use of multi-dose medication vials for more than one patient.

The Centers for Disease Control and Prevention Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (pgs. 36-37), stated thorough cleaning of instruments is required before sterilization to remove inorganic and organic materials which would interfere with the effectiveness of the sterilization process. Additionally, enzyme solutions should be used according to the manufacturer's instructions for proper dilution of the enzymatic detergent and contact with the equipment for the specified amount of time.

1. The facility failed to ensure the cleaning of surgical instruments was performed in accordance with manufacturer's instructions.

a) On 01/26/16 at 10:35 a.m., the cleaning process of surgical instruments was observed. Certified Surgical Technician (CST #13) was observed filling an unmarked metal basin with water and two dispensing pumps of Endochoice Pure Enzymatic Detergent. CST #13 stated the metal basin holds about 2 gallons of water and 1 pump of enzymatic cleaner was equal to about 20cc's (cubic centimeters) but s/he could not be sure of the amounts. CST #13 stated the enzymatic cleaner s/he was using was a sample provided by the product representative. S/he further stated the enzymatic cleaner which was normally used was measured in the same manner with exception of markings in the metal basin to show 1 and 5 gallon water measurements. According to the Pure Enzymatic Detergent manufacturer's instructions which CST #13 stated s/he uses, for Manual Cleaning: Add 1/2 fluid ounce of concentrate per gallon of water. Soak for 2-3 minutes. Rinse thoroughly.

CST #13 further stated the product representative for Pure Enzymatic Cleaner "told me the pump holds 1 ounce" of cleaner so s/he would use 1/2 a pump per gallon of water. CST #13 stated there was no written process/policy provided to him/her on the cleaning of surgical instruments. CST #13 stated s/he was in the process of preparing for Certification in Sterile Processing and relied on the instructions from his/her certification manual.

b) An interview was conducted on 01/26/16 at 1:46 p.m. with the Infection Preventionist (IP #6). IP #6 stated during Environment of Care (EOC) rounds s/he discussed infection control issues with each Department director but the surgical department had always been a "stand alone" department in charge of their own infection control processes.

c) In an interview with the Director of Surgery (Director #7) on 01/27/16 at 2:05 p.m. s/he stated a written procedure for the cleaning and sterilizing of surgical instruments would have been beneficial to ensure instructions on accurate measurement of cleaning solution and water were performed. Director #7 was not aware there was a new enzymatic cleaner used in the sterile processing area.

d) An interview was conducted with the Chief Nursing Officer (CNO #9) on 01/27/16 at 11:40 a.m. CNO #9 acknowledged s/he had supervisory responsibility over several departments including infection control. CNO #9 stated there should be a standardized written process for the cleaning of surgical instruments including accurate measuring of water and cleaning detergent "otherwise you can't be consistent or sure that you are performing the process according to regulation". CNO #9 stated s/he was not aware a new enzymatic cleaner was being used in the cleaning of surgical instruments.

2. The facility staff did not perform hand hygiene appropriately when performing patient care.

a) On 01/26/16 from 7:30 a.m. to 9:40 a.m. surgical staff in the operating room (OR) were observed. Certified Registered Nurse Anesthetist (CRNA #4) was observed performing patient care tasks and did not complete hand hygiene and/or glove changes as required by facility policy. CRNA #4 donned gloves without performing hand hygiene at approximately 8:20 a.m., after administering intravenous (IV) medication to the patient. Wearing the same pair of gloves CRNA #4 inserted a breathing tube into the patient's throat then changed gloves and began to withdraw medication without performing hand hygiene. At 9:05 a.m. CRNA #4, wearing the same pair of gloves, picked up a cell phone and placed it on the anesthesia cart. At 9:17 a.m. CRNA #4 wiped his/her own eye, touched the cell phone then withdrew medication from a medication vial and administered the medication into the patient's IV. At 9:40 a.m. CRNA #4 picked up his/her cell phone again, wearing the same pair of gloves, s/he then administered additional medication through the patient's IV.

b) In an interview with CRNA #4 on 01/26/16 at 11:08 a.m., s/he stated glove changes and hand hygiene were to be performed after every patient and between surgical cases and after eating or using the bathroom. CRNA #4 stated s/he performed hand hygiene before entering the OR and upon completing the case. S/he stated there was no way to clean his/her hands once in the OR.

CRNA #4 did not complete hand hygiene and glove changes over a 1 hour and 40 minute period during which s/he performed 5 separate direct patient care tasks.

c) An interview was conducted with the Director of Surgery (Director #7) on 01/27/16 at 2:05 p.m. Director #7 confirmed hand hygiene and glove changes should occur together and anytime a contaminated surface was touched and prior to performing a new patient care task. Director #7 stated alcohol-based hand sanitizer containers should be available inside the OR to clean hands which are not visibly soiled.

d) During the observations in the emergency room (ER) on 01/26/16 at 8:34 a.m. and 8:47 a.m. Registered Nurse (RN #14) was observed during the process of medication administration. RN #14 performed hand hygiene, removed a medication from the Pyxis (automated dispenser), rolled the work station on wheels (WOW) into a patient ' s room, handed the patient the medication, entered data into the WOW then washed his/her hands prior to leaving the patient area.

At 8:50 a.m. an interview was conducted with RN #14. S/he stated hand hygiene should be performed before and after touching a patient, before and after glove changes and between tasks or procedures. RN #14 acknowledged s/he should have performed hand hygiene after touching the WOW and before administering medication to the patient.

e) An interview was conducted on 01/26/16 at 8:45 a.m. with the Director of ER (Director #15). S/he stated nurses are supposed to perform hand hygiene before donning and after removing gloves; when leaving one patient's room and before entering a different patient's room; and after touching equipment in the immediate patient care area.

f) In an interview on 01/26/16 at 1:46 p.m. with the Infection Preventionist (IP #6), s/he stated the infection control guidelines utilized by the facility were the Centers for Disease Control and Prevention (CDC), the Association of preiOperative Registered Nurses (AORN) and the Association for Professionals in Infection Control and Epidemiology (APIC). IP #6 stated his/her responsibility for infection control included the entire facility except for the surgical department and ER because those departments independently monitored their own infection control process. IP #6 stated s/he did not spend time in the ER or OR performing infection control surveillance or educating because s/he assumed the directors were managing it. S/he stated hand hygiene and glove changes should occur together between unclean and clean tasks. IP #6 stated "I guess I need to spend some time in the OR working on hand hygiene".

3. The facility failed to maintain safe medication preparation and administration practices.

a) On 01/26/16 during a surgical procedure Certified Registered Nurse Anesthetist (CRNA #4) was observed from 7:30 a.m. until 9:45 a.m. administering intravenous (IV) medications. At approximately 8:15 a.m. CRNA #4 opened several medication vials at the beginning of the procedure, did not disinfect the medications ' stoppers, withdrew the medications then administered the medication without disinfecting the entry port on the patient's IV line. At 8:40 a.m. CRNA #4 was observed re-entering a multi-dose vial of IV medication with a used syringe and needle, without disinfecting the medication stopper.

b) In an interview with CRNA #4 on 01/26/16 at 11:08 a.m. s/he stated there was no supporting research to show disinfecting a newly opened medication vial stopper was necessary. CRNA #4 stated s/he had enough alcohol swabs in the anesthesia cart to perform disinfection of the multi-dose vial stopper prior to re-entry but did not think it was necessary during a procedure with the same patient. S/he confirmed a new needle and syringe should have been used when re-entering a multi-dose vial. CRNA #4 stated s/he was unaware of a policy on safe medication injection.

c) An interview was conducted on 01/27/16 at 2:05 p.m. with the Director of Surgery (Director #7). Director #7 stated each time a medication vial was opened the stopper should be disinfected with alcohol and multi-dose vials should be disinfected with alcohol prior to re-entry. S/he stated when withdrawing additional medication from a multi-dose vial a new syringe and needle should be used.

d) On 01/26/16 at 1:46 p.m. the Infection Preventionist (IP #6) was interviewed. IP #6 confirmed the use of several guidelines on infection control and nursing care including the Association of periOperative Registered Nurses (AORN) referenced previously. S/he also confirmed safe medication practice involved the cleaning of all medication vial stoppers prior to entry with a new needle and syringe. S/he confirmed multi-dose vials should not be re-entered with a used needle or syringe. IP #6 stated s/he assumed the director of the surgical department was managing the infection control surveillance and education within the department. IP #6 stated s/he did not spend much time in the surgical department or OR but discussed infection control needs with the department director during monthly environment of care rounds.

e) An interview was conducted with the Chief Nursing Officer (CNO #9) on 1/27/16 at 11:40 a.m. CNO #9 stated IP #6 has the authority to perform infection control surveillance in any area of the hospital and the role of the IP could be expanded and more structured. CNO #9 confirmed the use of safe medication injection practices should be adhered to.

4. The facility failed to ensure patient care equipment was disinfected between every patient.

a) On 01/26/16 at 8:34 a.m. and again at 8:47 a.m., Registered Nurse (RN #14) was observed in the emergency room (ER) performing patient care tasks. RN #14 removed medications from the automated dispenser, collected the Workstation on Wheels (WOW) from the main hallway, entered the room of Patient #19, donned gloves, and administered medication to the patient. No hand hygiene was performed until all care tasks were completed. RN #14 then moved the WOW from the room of Patient #19 and placed it in the main hallway where other patients and staff members passed through. No disinfection of the WOW occurred.

RN #14 prepared to administer additional medications at 8:47 a.m. RN #14 performed hand hygiene, removed medications from the automated dispenser, collected the same contaminated WOW from the main hallway and entered the patient's room, administered he medication to the patient, entered data into the WOW, then performed hand hygiene. RN #14 removed the WOW from the patient's room and placed the WOW in the main hallway. No disinfection of the WOW occurred.

b) At 8:50 a.m. RN #14 was interviewed. RN #14 stated the WOW's are disinfected every morning and evening to coincide with shift change and on occasion during the shift. S/he stated the policy does not require disinfecting of the WOW between patients.

c) In an interview with the Director of ER (Director #15) on 01/26/16 at 8:45 p.m., s/he stated the WOW's are cleaned at the beginning and end of each shift. Director #15 stated s/he was unsure how often the WOW's are cleaned between patients.

d) The Infection Preventionist (IP #6) was interviewed on 01/26/16 at 1:46 p.m. IP #6 stated the WOW's should not be touched with gloves on after touching the patient. S/he stated the reason gloves are worn was to prevent cross contamination from the patient to the WOW and then to another patient.


5. The facility failed to ensure food was identifiable, labeled, and dated with expiration or use by dates. Additionally, the facility failed to ensure food was discarded after the expiration date or use by date.

a) On 01/25/16 at 2:53 p.m., a tour of the main kitchen was conducted with the Chief Nursing Officer (CNO #9) and the Director of Facilities (Director #10). During the tour, inspection of the main kitchen's self serve refrigerator open to the public revealed the following items were expired. Five unopened cartons of 2% milk with manufacturer expiration date with 01/24/16.

b) During the tour, inspection of the back kitchen refrigerator and freezer revealed the following items were labeled with an expiration date and/or use by date:

One container of cheddar cheese with date with 01/19/16;

One large jar of cherries with date with 12/28/15;

One pack of plastic wrapped pepper Jack cheese with date with 01/24/16;

One pack of plastic wrapped Swiss cheese with date with 01/24/16;

14 stacked baking sheets of raw bacon topped with parchment paper with no date;

Inspection of the kitchen's Pepsi refrigerator revealed the following items were not dated or labeled with an expiration date and/or use by date:

One quart container of lettuce with date with 01/24/15;

One half quart container of sliced tomatoes with date with 01/24/15;

Two half quart containers of cut dill pickles with date with 01/24/15;

One half quart container of sliced onions with date with 01/24/15;

One container of sliced strawberries with no date;

One container whole blueberries with no date;

One container mixed fruit with no date;

Inspection of the kitchen's freezer revealed the following items were not dated or labeled with a received or an expiration date and/or use by date:

One box of pork loin chops;

One plastic freezer bag of pork chops;

One box of battered breaded mushrooms;

One box of fully cooked chicken;

Additional items were found throughout the kitchen and in the patient care unit. This inspection revealed the following items were removed from their original packaging without the expiration date being transferred to the individual items:

In the kitchen was a plastic container of mashed potatoes with no expiration date; however the original mashed potato container had an expiration date listed on the box.

On the patient care unit in the nutrition refrigerator revealed six 3-ounce containers of chocolate ice cream with no expiration dates.

c) On 01/25/16 at 3:30 p.m., an interview was conducted with a dietary staff member (Employee #1). S/he stated the kitchen aides were responsible for checking expiration dates in the main kitchen area. Employee #1 stated the dates on the beverages are checked every day by the kitchen aides and they were responsible for re-stocking the refrigerator. S/he stated when the aides find expired items the aides are to throw away expired items after the supervisor has been informed of the expired items. Employee #1 stated refrigerated items in the back kitchen were dated once they were opened. S/he also stated kitchen staff are responsible for monitoring and watching for outdates. Employee #1 also stated during orientation we were given a list of when food expired. Additionally employee #1 stated kitchen staffs were not required to take a food handler's course and there has been no further training since orientation.

d) On 01/25/2016, 1:56 p.m., an interview was conducted with the Kitchen Supervisor (Employee #13) who stated s/he usually ordered one week supply of food; however s/he also stated nothing stays in the freezer greater than 3 months. Upon request s/he was unable to provide a procedure to determine when items should be disposed of.

On 01/26/2016, 1:05 p.m., Employee #13 stated s/he had labeled all the food in the refrigerators and freezer with expiration dates and s/he had also went online to Foodgov.org and Washington State to establish a list of when foods will be outdated and stated the list was displayed in the kitchen for staff to refer to.

e) On 01/26/2015 at 1:46 p.m., an interview was conducted with the Infection Preventionist (IP #6). IP #6 stated s/he goes to the kitchen once a month. IP #6 also stated s/he did not inspect the kitchen nor monitors the food for outdates, and s/he was anticipating that the manager was good at her job and assumes the kitchen manager was checking for expiration dates.

Based on interviews and record review, the facility failed to ensure patient care policies were reviewed on a regular basis.

The failure created the potential for patients to receive inconsistent levels of care and created an unsafe setting.

Findings

Policy

According to the facility policy, Policy Development, policies should be reviewed at least annually.

Reference

According to the Bylaws of the Governing Board, adopted in May, 2014, the specific powers and responsibilities of the board was to develop, adopt, and implement policies and guidelines for the operation of the facility and review these guidelines and policies on an annual basis.

1. The facility failed to ensure healthcare policies were reviewed on an annual basis.

a) Review of facility policies revealed an Infection Control: Standard Precautions policy with a review date of April, 2011 and the Infection Control: Hand Hygiene policy was last reviewed in March, 2008. The Surgical Services: Asepsis policy had a review date of July, 2012.

b) Review of the Emergency Management Plan (EMP), which establishes the facility basic emergency preparedness program for the provision of a timely, coordinated, and integrated community response to natural and man-made disasters, was placed into effect in January, 2008. There was no record to show the EMP had been reviewed or revised.

c) In an in terview on 01/27/16 at 2:57 p.m. with the Director of Risk/Compliance/Quality (Director #11), s/he stated the facility policy on policy review did not dictate a frequency for policy review. Director #11 provided the facility policy noted above and stated "our policies have not been getting reviewed on a yearly basis". Director #11 stated none of the hospital-wide policies had been reviewed or updated in the last year.

Outdated patient care policies create the potential for patients to receive care which does not reflect up to date care practice.