Task 4- AFT 2- Ruby Duran
docx
keyboard_arrow_up
School
Western Governors University *
*We aren’t endorsed by this school
Course
AFT2
Subject
Health Science
Date
Jan 9, 2024
Type
docx
Pages
7
Uploaded by DrWaterBuffaloPerson994
XXXXXX XXXXX
AFT2- Accreditation Audit
KCM1- Task 4
Western Governors University
April 19th, 2023
A.
Compliance Status
Nightingale Hospital was found to be in compliance with the following Joint Commission standards. (The Joint Commission E-dition- 2020)
●
Accreditation Participation Requirements
●
Emergency Management
●
Infection Prevention and Control ●
Human Resources
●
Performance Improvement
●
Rights and Responsibilities of the Individual
●
Waived Testing
●
Transplant Safety
Nightingale Hospital was found to not be in compliance with ten Joint Commission standards out
of a possible eighteen total standards. Our accreditation status is at risk because of our compliance status within these standards. It is imperative that we take action to put Nightingale Hospital in compliance as soon as possible to provide our patients with the best care possible and
remain accredited with the Joint Commission. The review of our compliance with these standards uncovered the following standards not in compliance:
●
Environment of Care
○
Nightingale was found to be noncompliant with the Environment of Care standard
because there were smoke wall penetrations being noted in the FSA Finding documents. The hospital’s individual audit on Fire Drills also revealed that departments are not completing the drills as often as required.
●
Leadership
○
Nightingale was found to be noncompliant with the Leadership standard due to a shortage of nurses being scheduled which has caused lack of appropriate charting and low morale among nursing staff.
●
Nursing
○
Nightingale was found to be noncompliant with the Nursing standard due to the staffing patterns of the nursing staff. It was discovered that the hospital is not staffing the hospital with the correct ratio for the number of patients to the correct number of nurses. ●
Information Management
○
Nightingale was found to be noncompliant with the Information Management standard due to several uses of undefined abbreviations in the electronic medical records system and in several reports.
●
Record of Care, Treatment, and Services
○
Nightingale was found to be noncompliant with the Record of Care, Treatment, and Services standard due to several separate instances of verbal orders not being authenticated within the required forty-eight-hour period. ●
Medication Management
○
Nightingale was found to be noncompliant with the Medication Management standard due to several instances where nursing staff did not follow the hospital’s range ordering policy
●
Life Safety
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
○
Nightingale was found to be noncompliant with the Line Safety standard due to the hallways being blocked, specifically stretchers being placed in front of fire extinguishers and linen carts being placed in the hallway.
●
Provision of Care, Treatment, and Services
○
Nightingale was found to be noncompliant with the Provision of Care, Treatment, and Services standard due to missing records in the electronic medical record system of patient assessments and assessments of pain levels
●
National Patient Safety Goals
○
Nightingale was found to be noncompliant with the National Patient Safety Goals standard due to labels not being placed correctly on items within the operating room. ●
Medical Staff
○
Nightingale Hospital was found to be noncompliant with the Medical Staff standard because the hospital does not have an Ongoing Professional Practice Evaluation (OPPE) process in place.
B. Trends
In order to be proactive Nightingale Hospital completed several self-audits that allow us to notice trends both positive and negative. In this case, we have noticed several trends which have helped lead the hospital’s noncompliance in several areas. The first comes from the Fire Drill History document. The hospital requires fire drills to be completed and documented for each department and shift once per quarter. The Fire Drill history sheet showed that no department was in compliance with this standard. If these standards were followed, the hospital may have been less likely to have clutter in the hallways and objects obstructing fire exits and extinguishers.
Another troubling trend that was noticed from our Verbal Authorization review was a low number of verbal orders being entered to the electronic medical records system within forty-
eight hours, as is required by hospital policy which complies with the joint commission’s standards. During the review of the Verbal Order Audit, it was discovered that during several months the hospital entered less than eighty percent of verbal orders within forty-eight hours. C.
Staffing Analysis
During the review of the Staffing Effectiveness Report it was discovered that on the East 3rd floor Oncology unit, showed a decrease in falls and pressure sores on the floor. Due to this review of this floor, I would not recommend any changes to the staffing plan on this plan. Conversely, when reviewing the Staffing Effectiveness Report, it was discovered that on the 4th floor, the East wing showed a large increase of pressure sores and falls. I would recommend changes to the staffing plan for this area. While reviewing the effectiveness report, I noticed that there was a large increase in nursing care hours that heavily relied on asking our nursing staff to take on overtime hours. The revised plan will work to assign permanent staff to the floor, which will help with staff burnout. D.
Staffing Plan
In order to address some of the concerns, I am recommending that a policy be put in place to limit the number of patients any staff is responsible for at one time. This policy should be implemented for any level of care staff that are responsible for patient care, including physicians, registered nurses, licensed practical nurses, certified nursing assistants, etc. This policy should be implemented by our human resources department and re-evaluated every ninety
days. Furthermore, with this policy change our staffing plans will need to change as well and if a staff member is going to be over the maximum number of patients, changes to this plan should be made as quickly as possible to best serve our patients.
Staffing Plan for 4E
# Of Registered Nurses
# Of Licensed Practical Nurse
# Of Certified Nursing Assistants
Morning
12
10
10
Evening
7
7
12
Night
3
5
10
The staffing recommendation above for 4E, was written to allow for more registered nurses and licensed practical nurses during the day time to help with treatments, family visitation, turning patients, etc. The evening shift calls for less registered nurses since treatments and labs are less prevalent during these hours, on the flip side more certified nursing assistants are being used to assist with baths, turning patients, and getting them settled in for the night. During the night shift, the recommendation is for less registered nurses and licensed practical nurses since patient treatment and other labs are far less common overnight.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
References
The Joint Commission E-dition, Accreditation Requirements. (2020). Retrieved April 20, 2023, from https://e-dition.jcrinc.com/MainContent.aspx