HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the governing body provided oversight of the hospital policy and procedures for 17 0f the 17 policies reviewed, potentially effecting the safety of all current and future patients.

Findings:

A review of the 7 policies below showed a name for another hospital (names omitted) and no policy for the hospital being surveyed:
1. Quality of Care dated 01/15/2016;
2. Credentialing and Privileging Process dated 01/15/2016;
3. Telemedicine Services (no date);
4. Assessment dated 08/24/2016;
5. Access and Visitation Rights (no date).
6. Nutritional Plans of Care dated 04/13/2016.
7. Enteral and Total Parenteral Nutrition dated 04/13/2016.

A review of the following 11 of 17 policies showed no effective date of the policy:
1. Telemedicine Services;
2. Access and Visitation Rights;
3. Swingbed Services;
4. Patient Assessment;
5. Rehabilitation Services for Patients Admitted to Swing Bed;
6. Pain Scale;
7. Nutritional Consults;
8. Nutritional Screening-Monitoring;
9. Complaint and Grievance;
10. Cleaning a Patient Room-Occupied Quality of Care Concerns;
11. Allegations of Abuse and Neglect.


A review15 of the 17 policies below were not updated every 2 years.
1. Quality of Care dated 01/15/2016 unable to determine when the policy was last updated.
2. Credentialing and Privileging Process dated 01/15/2016 unable to determine when the policy was last updated.
3. Telemedicine Services (no date) unable to determine when the policy was last updated.
4. Assessment dated 08/24/2016 unable to determine when the policy was last updated.
5. Access and Visitation Rights (no date) unable to determine when the policy was last updated.
6. Nutritional Plans of Care dated 04/13/2016 unable to determine when the policy was last updated.
7. Enteral and Total Parenteral Nutrition dated 04/13/2016 unable to determine when the policy was last updated.
8. Swingbed Services has (no date) unable to determine when the policy was last updated.
9. Patient Assessment has (no date) unable to determine when the policy was last updated..
10. Rehabilitation Services for Patients Admitted to Swing Bed has (no date) unable to determine when the policy was last updated.
11. Pain Scale had (no date) unable to determine when the policy was last updated.
12. Nutritional Consults hda (no date) unable to determine when the policy was last updated.
13. Nutritional Screening-Monitoring has (no date) unable to determine when the policy was last updated.
14.0Cleaning a Patient Room-Occupied (no date) unable to determine when the policy was last updated
15. Allegations of Abuse and Neglect (no date) unable to determine when the policy was last updated

On 11/08/24 at 1:00 p.m. employee L stated they had not updated some policies to reflect the current facility's name and they could not tell when the policies were updated.

On 11/08/24 at 1:20 p.m. employee L stated some of the policies were updated but the updates were not documented on the policy. They are effective now, but it is not on the policy.

On 11/08/24 at 1:40 p.m., employee L stated that they would have to look up the last time the policies were updated.