HospitalInspections.org

Based on hospital document review and staff interviews, the critical access hospital (CAH) failed to ensure policies and procedures were reviewed and updated as needed annually.

Findings:

1. On September 8, 2015 at 10:15 a.m. surveyors requested CAH policies and procedures. Administrative staff provided multiple binders with CAH policies and procedures. All CAH policies and procedures with the exception of physical therapy and radiology had no documented evidence that the CAH policies and procedures were reviewed, updated, and approved annually.

2. On September 8, 2015 at 10:30 a.m., surveyors reviewed the CAH's policy and procedure manuals. The nursing policy and procedure table of contents contained policies and procedures for services such as surgery that were not offered at the CAH.

3. On September 8, 2015 at 11:57 a.m. the director of nursing (DON) told surveyors that all nursing policies and procedures had not been updated in quite some time.

4. On September 9, 2015 at 10:45 a.m. the chief executive officer (CEO) told surveyors that all policy and procedure manuals had not been updated, reviewed, and been approved through the medical staff or governing body.