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Based on policy and procedure review and staff interview, the facility failed to ensure patient care policies met the annual review requirements. The annual review was lacking for 10 of 23 policies reviewed (surgical services, rehabilitation, emergency services, and advance directives). The findings were:

1. Review of the policy and procedures for surgical services, rehabilitation, emergency services and for advance directives showed they lacked evidence of annual review. Review of the Banner Health Policy and Procedure Requirements, with a revision date of 4/18/19 showed "...9. All policies are reviewed every three years unless otherwise required to be reviewed more frequently by federal, state, or local law, regulatory agencies or accrediting bodies...". Interview with the CNO (chief nursing officer) on 9/18/19 at 4:38 PM revealed the facility used both facility-wide and system-wide policies and procedures. She stated the system-wide policies and procedures were reviewed every three years, and facility-wide policies were reviewed annually. She further stated the system-wide policies were not compliant with the annual review. The review dates included:
a. Review of the system-wide policies and procedures related to surgical services showed "Perioperative Services-Intraoperative Standard of Care" with a review date 1/8/18, "Administration of Anesthesia" with a review date 10/17/17, "Discharge Criteria for Patients Discharged Post Sedation of Anesthesia" with a review date 4/24/18, and "Endoscopy-Care and Cleaning of Immersible Flexible Endoscopes and Endoscopic Accessories" with a review date 1/3/18.
b. Review of the system-wide policy "Rehabilitation-Admission and Discharge Criteria for Rehabilitation" showed a review date of 10/3/17.
c. Review of the system-wide policies related to emergency services showed "Emergency Department Standards of Care" with a review date 10/9/17, "Emergency Medication Containers" with a review date 10/4/17, "EMTALA-Medical Screening Examination and Stabilization" with a review date 5/16/18, and "Provision of Appropriate End of Life Care" with a review date 4/20/18.
d. Review of the policy and procedure titled "Advance Health Care Directives of Wyoming", showed the last revision date was 11/5/18.
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Based on observation, review of policies and procedures, and staff interviews, the facility failed to ensure staff adhered to infection control practices related to blood spills and wearing eye protection during blood and tissue dispersion. These failures were identified during 1 of 2 observations of operative and post-operative care and 1 of 1 observation of terminal cleaning. The findings were:

1. Observation with the intra-operative manager on 9/18/19 at 3:51 PM showed staff completed the surgical procedure in operating room #2 and wheeled the patient to the recovery area. Observation of the operating room at 4:30 PM showed a large area of blood drainage was on the floor extending from the end of the operating table to other areas of the room. Further observation showed bloody foot prints throughout the room and tracks leaving the room. Interview with the intra-operative manager at that time revealed the expected standard of practice for the operating room staff was to clean blood drainage from the floor promptly to prevent tracking to other areas. Review of the September 2016 Centers for Disease Control and Prevention publication titled, "Guide to Infection Prevention for Outpatient Setting" showed staff should appropriately clean and decontaminate spill of blood or other potentially infectious material promptly. Review of the policy and procedure titled, "Biohazardous Waste," revised 4/29/19 showed procedures for responding to blood and blood product spills included instructions for containment, disinfection and preventing contamination.

2. Observation with the facility educator on 9/18/19 at 8:51 AM of a patient surgical procedure showed the RN (registered nurse) circulator, the surgeon, and the instrument sales representative failed to have eye protection. Continued observation showed the procedure caused tissue dispersion. Review of the Standard and Transmission Based Precautions policy, with a review date of 8/6/19 showed "...Wear a mask with eye protection...during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions...". Interview on 9/18/19 at 4:30 PM with the CNO revealed her expectation was for staff to wear appropriate eye protection when in contact with blood and body fluids.
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Based on review of policy and procedure, medical record review, and staff interview, the facility failed to ensure the clinical records system was maintained based on established policy and procedures for 6 of 28 patient records (#21, #22, #24, #25 , #26 , #27 ). The findings were:

1. Review of the policy and procedure titled "Medical Staff Rules and Regulations" showed: The patient's medical record shall be completed within 15 days after discharge, including progress notes, final diagnosis and dictated discharge summary..." The following concerns were identified:

a. Review of the medical record for patient #21 showed voice orders dated 8/27/19 and 8/29/19 that were not signed by the physician.
b. Review of the medical record for patient #22 showed on 8/26/19 H & P (history and physical) was not signed by the physician. Further review showed the 8/28/19 Operative Note and Discharge Summary was not signed by the physician.
c. Review of the medical record for patient #24 showed 8/27/19 H & P and 8/28/19 Discharge Summary was not signed by the physician.
d. Review of the medical record for patient #25 showed the patient had surgery on 8/29/19. Further review showed an operation report was lacking.
e. Review of the medical record for patient #26 showed the patient had surgery on 8/29/19. Further review showed an operation report was lacking.
f. Review of the medical record for patient #27 showed the patient was stabilized; then transported to another hospital on 8/11/19. Further review showed the H & P and discharge summary reports, both dated 8/11/19, had not been signed by the physician.
g. On 9/18/19 at 3:40 PM interview with HIM (health information management) technician #1 verified the medical records for patients #21, #22, #24, #25, #26, and #27 were incomplete and did not meet the facility requirements for signing and completing orders, history and physicals, discharge summaries, and operative reports. She stated it was difficult trying to get the physicians to address the incomplete areas in the medical records after the patients were discharged. She further stated various approaches had been implemented, but she was unsure if any of the approaches were effective because it continued to be a problem.