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Based on policy and procedure review and staff interview, the facility failed to ensure physicians and nurse practitioners developed and periodically reviewed policies and procedures.

Findings Include:

Review of the facility's policies and procedures revealed no documented evidence they had been reviewed or updated since 2011 and there was no policy for updating policies.

On 9/16/14 at 1:30 p.m. the Assistant Director of Nursing confirmed the policies had not been reviewed or updated by the physicians and nurse practitioners.

No further documentation was offered during the exit conference on 09/17/14 at 10:30 a.m.

Based on record review, document review, policy and procedure review and staff interview, the facility failed to ensure physicians reviewed and signed six (6) of six (6) records of patients cared for by nurse practitioners.

Findings Include:

Record review revealed the physician had not signed behind the nurse practitioner in the computer records for Patient #1, #2, #3, #4, #5 and #6.

During an interview on 9/17/14 at 9:30 a.m. the Director of Medical Records stated the physician always signs behind the nurse practitioner. After she reviewed the six (6) records, she stated they were supposed to have both electronic signatures.

Review of the facility's Medical Staff ByLaws revealed no documented evidence of this requirement of the physicians.

During the exit conference on 09/17/14 at 10:30 a.m. these findings were discussed. No further documentation was submitted.

Based on document review, staff interview and policy review, the facility failed to ensure that their formulary had been approved by the Pharmacy and Therapeutics Committee and failed to ensure Pharmacy and Therapeutics Committee met four (4) times annually.

Findings Include:

Review of the hospital's formulary on 9/17/14 at 9:35 a.m. revealed that there was no documented evidence that the formulary had been approved by the Pharmacy and Therapeutics Committee.

Interview with the Director of Nursing on 9/17/14 from 11:15 a.m. to 11:20 a.m. revealed that there was no documented evidence that the Pharmacy and Therapeutics Committee met during the last 12 months.

Review of the facility's "Pharmacy and Therapeutics Committee" policy revealed, "The committee will meet no less than four times annually."


Review of the facility's "Formulary Policy" revealed, "The formulary will be revised and approved by the P&T Committee annually."

Based on policy review, staff interview and record review, the facility failed to ensure six (6) of six (6) patient records reviewed were easily accessible.

Findings Include:

Review of the facility's policies and procedures revealed no documented evidence of a policy regarding access to medical records.

During the survey process the six (6) medical records requested were not easily accessible for review. The facility submitted the records piece by piece over the course of the survey.

On 9/17/14 at 10:00 a.m. an interview with the Medical Records Director and the Assistant Director of Nursing revealed that they neither one knew that they could not print a whole record. The Medical Records Director stated, "There are parts of the record I did not have access to."

Based on staff interview, policy and procedure review and staff interview, the facility failed to ensure their health care policies are reviewed annually

Findings Include:

Review of the facility's policy and procedure manual revealed no signature sheets or documented evidence the physician and nurse practitioners had met annually to review and update the facility's policies. There was no documented evidence of a policy requiring the review and update of the facility's policy and procedures.

During an interview on 9/16/14 the Assistant Director of Nursing confirmed their policies had not been reviewed or updated annually. She stated, "I was told we don't have to have a sign in review cover sheet. But they haven't been updated."

During the exit conference on 9/17/14 at 10:30 a.m. the above evidence was presented and no further documentation was offered.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure seven (7) of seven (7) patients reviewed had comprehensive care plans.

Findings Include:

Review of the computer generated Care Plan problem activity sheets in the seven (7) patient records reviewed revealed no documented evidence that problems were addressed, of any goals or of re-evaluations. There was no documented evidence of participation by a physician in the Comprehensive Care Plan. This was confirmed by the Assistant Director of Nursing on 9/17/14 at 9:30 a.m.

Review of the facility's "Care Planning" policy (effective 04-05-13) revealed, "The plan of care shall be individualized based on diagnosis, patient assessment, and personal goals of the patient and family."

In the exit conference on 9/17/14 at 10:30 a.m. the above evidence was presented and no further documentation was offered.