The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ADVENTHEALTH SEBRING||4200 SUN N LAKE BLVD SEBRING, FL 33872||April 19, 2016|
|VIOLATION: ORGANIZATION OF NURSING SERVICES||Tag No: A0386|
|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.
A review of sampled nursing policies and procedures revealed the following policies were not reviewed annually:
Verbal Orders (POC ), approved 10/2010-No Further Review
Orders Processed for CPOE (AHS-CW-CPOE-101) approved 11/12/2014-No Further Review
Incident Reporting & Review, (RM ), approved 9/18/2014- No Further Review
Blood Transfusion and Reaction, (GN ), approved 9/2011-No Further Review
Reassessment Policy, (GN ), approved 8/2008-No Further Review
Assessment/Reassessment, (No Policy Number), 5/2013-No Further Review
Orders Physician & Resolution, (GN ), approved 12/2011-No Further Review
Conflict of Care with Hierarchy, (APM ), approved 12/2013- No Further Review
Vital Signs Protocol, (GN ), 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.