Accreditation Audit Task 3

.docx

School

Pellissippi State Community College *

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Course

C206

Subject

Accounting

Date

Jan 9, 2024

Type

docx

Pages

5

Uploaded by jlluker

Accreditation Audit Task 3 1 Accreditation Audit Task 3 Jordone Luker RN MSN WGU 12/3/2023
[SHORTENED TITLE UP TO 50 CHARACTERS] 2 Abstract The focus of this tracer case study is 67-year-old female who was admitted multiple times to Nightingale Community Hospital post laparoscopic hysterectomy. The patient developed fever and drainage seven days post operation resulting in an admission for surgical abscess debridement and central line insertion. The patient’s chart was selected for review by the Joint Commission. Tracer methodology is used to assess a patients experience from the beginning of care to discharge and follow up. Information found on-site is used by the surveyors to assess the patients experience in the hospital also assess the different transitions of care to identify areas where performance standards are not being met (Joint Commission, 2023). A tracer will show all treatments received, all services provided, and documentation of the care received by the patient from each team member.
[SHORTENED TITLE UP TO 50 CHARACTERS] 3 Accreditation Audit Task 3 After careful and thorough review of the tracer tools, it was determined that Nightingale Community Hospital committed several violations regarding the referenced patient. Violations were found all throughout the continuum of care. For this case study, failure of closed loop communication will be the topic of this review. Closed loop communication means that when a team member gives an order or reads a lab value, the receiving member should verbally repeat beck what was stated ensuring handoff of proper information. Regarding the 67-year-old female patient, the Nurse failed to read back critical lab values when they were reported to her. Failure to perform the read back and closed loop communication can easily result in patient harm and inadequate care of the patient. Lab values, if they are not reported properly the patient can decline because no one will adjust the plan of care if the care team is not properly updated of the critical labs. Failure to comply to the read back method is in violation of the of the Joint Commission standard PC.02.01.03. The standard states the hospital will provide proper care and follow through with services ordered and prescribes in accordance to the laws and standards (Joint Commission, 2023). Action Plan In order for Nightingale Community Hospital to be in compliance with Joint Commission standards, changes must take place. The action plan to address the read back method will be addressed as follows. Education trainings will be set up for every unit in the hospital. This will ensure the staff are properly educated on the read back method and closed loop communication. This training course will also address the importance of the read back method and address possible outcomes if it is not done correctly. 4 Training courses will be provided in each unit at 0600 and 1800 after the training material has been approved. The units will be notified of dates
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