Acceditation Audit AFT Task 4

1003 Words Apr 27th, 2014 5 Pages
Accreditation Audit AFT Task 4.

A1. Compliance Status
The ongoing survey readiness audits that are conducted in the hospital on a daily basis have identified areas we will focus on to ensure that our accreditation survey results are exceptional. Audits are performed on an ongoing basis with a focus on trends that are most commonly cited by the Joint Commission. Nightingale hospital has proven to have made great improvements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, Treatment and Services, Information Management, Handoff Communication and critical value reporting. We have placed an abundance of resources and efforts into improvement in these
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This increased focus should prove to decrease the number of falls per 1000 days.
Action Plan:
1) Mandatory education by 4/15/2014 to all staff on 4E
2) All patients will be rounded on hourly beginning 4/16/2014
3) All hourly rounds will address the 4 P’s (Pain, potty, possessions and position)
a. Pain
i. Is patient experiencing pain at this time ii. If so, ask patient to rate their pain iii. Depending on pain level, offer medication or other intervention
b. Potty
i. Does the patient need to use the restroom, urinal or ambulate to bathroom and if so, assist them to prevent falls and stay with them until completed
c. Possessions
i. Is call light, phone, meals, etc… within reach of patient? The patient having their possessions within reach will minimize their need to reach or ambulate without assistance to answer the phone, etc… which will prevent falls

d. Position
i. Is it time to change the patient’s position (left to right, ambulate, etc…) the changing of position frequently will assist in the prevention of pressure ulcers.

4) Each staff member ta performs the hourly round will document each round on the rounding log that will be located in the patient room. Rounds can be done by either the nurse or nurse’s assistant, as long as all needs for medication or other special needs will be immediately addressed by the nurse.
The action plan presented

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