HospitalInspections.org

Based on review of facility documents and staff interviews, the hospital failed to ensure that patient care policies were reviewed at least annually by the group of professional personnel required to oversee policy/procedure development, review and revision.

Findings:

1. The facility failed to ensure that the Policy and Procedure Committee, reviewed all patient care policies/procedures at least annually. The failure to ensure that all policies/procedures were accurate and up-to-date created the potential for negative patient outcome.

a) Review of facility policy/procedure manuals on 08/08/13 revealed the following findings:
- The Infection Control Manual had not been reviewed since 2005.
- The Emergency Department had one policy/procedure that was most recently updated in 2011. The rest of the policies/procedures had 1 with last review date of 1999, 1 with a last review date of 2000, 5 with a last review date of 2001, 5 with a last review date of 2002, 29 with a last review date of 2003, 2 with a last review date of 2004, 2 with a last review date of 2005, 1 with a review date of 2006, 2 with a review date of 2008. No policies/procedures were reviewed after that date.
NOTE: The hospital trauma manual, which had similar policies and procedures, did have more recently reviewed policies, in preparation for a recent state trauma survey.
- The Surgery Manual had not been reviewed since 2009, per the signature sheet in the front of the manual.
- The Radiology Manual had some policies/procedures that had been reviewed in the past year, but the many of the policies/procedures list in the table of contents had not been reviewed for several years, and several went back to 1997.
- The Laundry Manual was last reviewed in June, 2008.
- The Housekeeping and Laundry/Linen Manuals, that were the products of the contractor that provided those services, had last review dates for 2003, 2004, 2005 and one policy for 2006.
- The Facility-wide Manual showed evidence of extensive efforts to review policies and procedures in particular departments in 2011, 2012 and 2013, but there were still many policies/procedures that had not been reviewed in over 5 years, or more, with some going back to 2000, and 1997.

b) These findings were confirmed with the administrator and the compliance manager during several interviews throughout the survey and at the exit conference on 08/09/13, at approximately 12:30 p.m.. They both re-confirmed what they had stated at the entrance conference on 08/05/13, that they had made a concerted effort after that last survey in 2008, to establish a committee of providers to review policies/procedures and to ensure that department directors were reviewing and revising their policies and procedures. The administrator stated that they were utilizing the new committee to review policies/procedures, as the they were updated by the managers. That was evident in review of the meeting minutes for that committee, during the survey. The administrator state that the department managers would be held accountable for completing a review/update of all of their polices/procedures during the next one-year performance review cycle. That plan was also confirmed by the compliance manager.