HospitalInspections.org

Based on review of policies and procedures and staff interviews it was determined the facility failed to review nursing policies and procedures periodically or have policy in place for when policies should be reviewed by the director of nursing.

Findings included:

A review of sampled nursing policies and procedures revealed the following policies were not reviewed annually:
Verbal Orders (POC04003), approved 10/2010-No Further Review
Orders Processed for CPOE (AHS-CW-CPOE-101) approved 11/12/2014-No Further Review
Incident Reporting & Review, (RM98001), approved 9/18/2014- No Further Review
Blood Transfusion and Reaction, (GN95028), approved 9/2011-No Further Review
Reassessment Policy, (GN95126), approved 8/2008-No Further Review
Assessment/Reassessment, (No Policy Number), 5/2013-No Further Review
Orders Physician & Resolution, (GN95069), approved 12/2011-No Further Review
Conflict of Care with Hierarchy, (APM95023), approved 12/2013- No Further Review
Vital Signs Protocol, (GN94038), approved 4/2007-No Further Review

An interview on 04/19/2016 with the nursing director and risk manager revealed there was no policy outlining when nursing policies should be reviewed. They were unable to determine if the policies were in compliance with quality of care initiatives with process improvement.