AFT2 T4

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Western Governors University *

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Health Science

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Jan 9, 2024

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docx

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1 AFT2 Task 4 Cassandra Marker Western Governors University Austin Arenz June 27, 2023
2 AFT2 T4 Nightingale hospital has been preparing for our upcoming Joint Commission review. In an effort to have a successful survey, we will undergo a compliance audit to ensure all 18 accreditation standards fall within compliance. For the areas identified as noncompliant, we will evaluate the findings for any noticeable trends and recommend action that should be taken as a result. We will also review the hospital staffing plans to ensure they support high quality care. A1. Compliance Status Below you will find all 18 accreditation requirements and their compliance status for Nightingale hospital. 1. Accreditation participation Requirements has been deemed compliant. By following these standards Nightingale can promote patient safety, work on continuous improvement, standardize best practices, and provide quality care to our patients. 2. Environment of Care requirements have shown noncompliance in EC.02.03.01 smoke walls are penetrated of 1 st and 4 th floor, EC.02.03.03 inconsistent fire drills, and EC 02.05.09 the alarm panel for medical gasses was not tested per policy. 3. Emergency Management has been deemed compliant. By following these standards, Nightingale can effectively respond to emergencies, protect both patients and staff, and maintain a high standard of care during challenging situations. 4. Human Resources has been deemed compliant. By following these standards Nightingale can provide a supportive work environment to its employees, attract as well as retain quality employees, and help assist the facility in regulatory compliance.
3 5. Infection Prevention and Control has been deemed compliant. By following these standards Nightingale helps to protect patients from hospital acquired infections, help prevent the spread of drug resistant infections, and prevent the overuse of antibiotics. 6. Information Management requirements have shown noncompliance in IM.02.02.01 prohibited abbreviations were found on 3E, and 4E, and ICU. 7. Leadership requirements have shown noncompliance in LD.03.06.01 nursing units demonstrating high overtime and low morale. 8. Life Safety requirements have shown noncompliance in LS.03.01.20 clutter in the hallways on 3E, 4E, OR, tele, ICU. LS.01.02.01 no ILSM found for 3 projects. LS.03.01.35 improper sprinkler clearance. 9. Medication Management requirements have shown noncompliance in MM.04.01.01 nurses could describe range dose policy on ICU, and MM.05.01.09 propofol was found unlabeled in OR and cath lab. 10. Medical Staff requirements have shown noncompliance in MS.08.01.01 OPPE process does not meet standards. 11. National Patient Safety Goal requirements have shown noncompliance in NPSG.03.04.01 unlabeled medications and bins found in OR 12. Nursing requirements have shown noncompliance in NR.02.02.01 nurses not documenting in a timely manner on 3E. 13. Provision of Care requirements have shown noncompliance in PC.01.02.03 procedure reassessment missing in cath lab and endo. PC.01.02.07 reassessment missing in the ED. PC.03.01.03 lack of presedation ASA and no documented plan of anesthesia noted in endoscopy.
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