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Based on interview and record review the facility did not review or update their policies and procedures to maintaining current best practices for standards of care which had the possibility to lead to substandard patient care and adverse clinical outcomes.

Findings:

On 9/9/19 at 3:00 pm, a review of the facility's Policy Manual indicated that polices and procedures in the Manual had not been reviewed annually.

During an interview on 9/9/19 at 4:30 pm, the Emergency Room Registered Nurse (RN 1) and Director of Nursing (DON) confirmed that the policies and procedures did not reflect current review dates.

The "Policy Development and Review - Acute/SNF/ER/Clinic" policy and procedure dated 7/26/17, was reviewed and indicated that policies and procedures were required to be reviewed "yearly." Both RN 1 and the DON confirmed the policy for review was not being followed as policies have not been reviewed and review dates have not been updated annually as required.


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Further review of the facility's policy titled "Policy Development and Review Acute/SNF/ER/Clinic," dated 7/26/17, indicated that as regulations and/or best practices change, policies were to be revised and references to professional standards of practice listed on the policy.

During a review of the facility's Central Supply Department policy and procedure manual on 9/10/19, a signature page at the front of the manual was present, indicating the manual had been reviewed 8/19. Verification signatures on the page included the Administrator, Medical Staff, Central Supply Department Manager (CSM) and Board of Directors Member. It was noted that neither the Director of Nursing (DON) nor the Laboratory Manager/Infection Prevention (LAB/IP) reviewed the manual.

Policies/procedures in the manual included "Preparation of Sterile Supplies," "Cleaning Instruments," "Protocol for Cleaning Dirty Instruments," and "Loading of Sterilizer." None of the policies/procedures in the manual had effective, approval and/or revision dates. There were no references to professional standards of practice or manufacturer instructions for use (IFUs) listed on the policies/procedures.

Policies/procedures in the manual did not address current standards of practice for cleaning, disinfection and sterilization of reusable instruments, including use of an enzymatic cleaner (used to break down proteins and soil such blood, serum, and tissue) as part of the cleaning process, maintaining hinged instruments in an open position during sterilization and use of reusable cloth wrappers for sterilization of basins and instrument sets.

During an interview on 9/10/19 at 10:00 am with CSM, she stated the LAB/IP had not been directly involved in the Central Supply Department policies and procedures review/approval process.

During an interview on 9/10/19 at 4:30 pm with LAB/IP, she stated she was not involved in the review/approval of the Central Supply Department policy/procedure manual.