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ESSENTIA HEALTH SANDSTONE
PATIENT CARE POLICIES
Tag No.: C1006
Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the nursing department were reviewed every two years.
Findings include:
Review of provisions of services polices and surgical services policies revealed the following were not reviewed biannually:
Provisions of Services
-Policy and Standard Work (Procedure) Management last review date: 9/29/21.
Surgical Services
-Outpatient Surgery Procedural Standard of Care last review date: 8/11/2020.
During an interview on 7/9/25 at 11:45 a.m., operations manager (OM) and Hospital Quality Partner (HQP) reviewed the policies and confirmed they were out of date. OM and HQP indicated the facility was working on getting all policies reviewed and up to date. OM and HQP further indicated they were aware policies needed to be updated every two years.
PATIENT CARE POLICIES
Tag No.: C1008
Based on interview and document review, the critical access hospital (CAH) failed to ensure it had policies and procedures for visitation rights of its patients.
Findings include:
During a review of the patient visitation rights, it was noted there was not a policy related to this.
During an interview on 7/9/25 at 1:00 p.m., the operations manager (OM)-B confirmed the CAH did not have a policy related to patient visitation rights.
A policy regarding patient visitation rights was requested however not received.