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Tag No.: C0272
Based on record review and interview, it was determined that the facility failed to ensure that patient care policies are reviewed at least annually by the required group of professional personnel.
Findings include:
Review on 7/23-7/30/19 of the 112-page hospital document of Monadnock Community Hospital Policies dated 7/23/19 revealed that most policies are identified as either Administrative, Clinical, or departmental. Also, the Approval Flow and date Last Approved is documented. A review of Clinical policies revealed that some approval dates were more than one year old. For example, the Administration of IV Immune Globulin (IgG) policy was last approved 1/1/15, with pending status in approval process; Medical Staff Bylaws were last approved 12/6/17; the Medications, Sample policy was last approved 4/22/15; the ICD Activity Guidelines Post Device Implant policy was last approved 9/1/17; the Blood Glucose Testing & Monitoring policy was last approved 9/1/17, with pending status in approval process; the Patient Assessment and Reassessment policy was last approved 4/22/15; the Code Carts policy was last approved 9/1/15, with pending status in approval process; and the Therapeutic Phlebotomy policy was last approved 9/30/17, pending status in approval process. Review of a subsequently obtained copy of the Therapeutic Phlebotomy policy, documented as "Retrieved 07/24/2019" on Page 1, reveals in the heading that it was Last Approved "07/2019".
Review of the hospital "Policy Management" policy, last approved "03/2019" revealed in part that "9. Policies will be presented for review and final approval by signature as follows: a. Patient Care Policies - Clinical Leadership Committee, Chief Nursing Officer, Chief Medical Officer, MHP Medical Director or when applicable, the departmental medical director and P&T when applicable ...."
Interview on 7/23/19 at about 1:30 p.m. with Staff G (Contract Specialist) revealed that policies are reviewed yearly if clinical, every three years if non-clinical; and clinical policies are reviewed by the CMO (Chief Medical Officer) or CNO (Chief Nursing Officer), and the Clinical Leadership Committee reviews some polices if they cross over more than one department.
Review of the document Clinical Leadership Committee (C.L.C.) Member List last updated 5/28/19 reveals that the Members section listing includes no physician or mid-level practitioners; a separate section entitled "Ad Hoc Members (Directors are Ad Hoc, department members are primary)" does include some mid-level practitioners.
Review of the Monadnock Community Hospital Policies list dated 7/23/19 revealed that not all Clinical policies are designated as passing through the CLC (Clinical Leadership Committee) in their Approval Flow. Examples of such include the Chemotherapeutic Agents, Administration of Parenteral policy; the Oxygen by Venturi Mask policy; the Policy on Cleaning Endoscopes; Surgical Hand Scrub policy; the Oxygen Titration policy; PACU Pediatric Patients Practice Guideline; and the Code Blue (Adult) & Code Pink (Child) - Cardiac Arrest-Medical Emergency policy. Some Clinical policies that include CLC in their Approval Flow do not include a physician (e.g. Chief Medical Officer) in their pathway; for example: the Pain and Comfort Management policy, and the Patient Controlled Analgesia policy.
Interview on 7/25/19 with Staff A (Chief Nursing Officer) confirmed that some policies are beyond one year since their last review. During review of the CLC Members List with Staff A, Staff A confirmed that there are no APRNs in the Members section of the CLC Members List, but there are two APRNs in the Ad Hoc Members section.
Tag No.: C0276
Based on observation, interview and review of facility policy, it was determined that the facility failed to ensure that access to medications is limited to clinical staff, in accordance with its policy, for one on-campus and one off-campus practice observed during the hospital survey.
Findings include:
The off-site location for Jaffrey Rehabilitation was toured on 7/24/19 a.m. with Staff F (Risk Management). Observation at this time revealed two office staff at the front desk: Staff D (occupational therapy) and Staff E (Office Assistant). Staff D obtained the key for the medication refrigerator from a key locker with a combination lock, by entering the combination. Staff D unlocked the medication refrigerator, which had no meds stored within.
Interview with Staff C (CMA) on 7/24/19 a.m. revealed that occasionally there are medications for patient use stored in the locked refrigerator, and that the combination to the key locker is available to office staff.
The on-campus practice of Internal Medicine was toured on 7/25/19 a.m. Observation at this time revealed medications stored in a locked cupboard and also medications, including immunizations, stored in a locked medication refrigerator.
Interview on 7/25/19 a.m. with Staff B (practice manager) revealed that Staff B has keys to the cupboard, which includes samples, and the refrigerator, and can access meds to assist when clinical staff are busy, and to check expiration dates. Staff B related s/he is not clinical staff.
Review of the hospital's policy for "Medications, Sample" Last Approved "04/2015" revealed in part that "All medication will only be handled by the clinical team. Non-clinical employees will not have access to these medications."
Interview on 7/25/19 at about 12:20 p.m. with Staff A (Chief Nursing Officer) on confirmed that neither Staff E nor Staff B should have access to medications.