HospitalInspections.org

Based on document review and staff interview, the facility failed to have all required personnel to assist in developing and updating policies and procedures.

Findings Include:

Review of the facility's policies and procedures developed, reviewed and rewritten in 2015 revealed they had a Physician's signatures but not a Nurse Practitioners or Clinical nurse specialist's signature. There was no documented evidence that one member who assisted in the process of developing and reviewing the policies and procedures annually was not a member of the critical access hospital staff as required.

On 08/18/15 at 10:15 a.m. the Director of Nursing stated she was not aware a mid-level nurse should be involved in the process of developing the new updated policies and procedures. She also stated she was not aware she needed an outside person, not employed by the facility, to assist in this group.