Accreditation Audit

1805 Words Apr 20th, 2015 8 Pages
Accreditation Audit
AFT Task 4 Regulatory Audit Organization Plans Compliance

Facility Compliance
The following represents the level of compliance in the pain assessment area of patient care that was audited for Nightingale Community Hospital:
There were 3 departments audited for Pain Assessment compliance over a 12 month period, NIGHTINGALE COMMUNITY HOSPITAL averaged 86.94% compliance. Audit | Audit Period | Location | Compliance % | Pain Assessment | 12 Months | ED | 70.66% | Pain Assessment | 12 Months | 3E | 93.5% | Pain Assessment | 12 Months | PACU | 96.66% |

There were 3 departments audited for Pain Reassessment compliance over a 12 month period, NIGHTINGALE COMMUNITY HOSPITAL averaged
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Some items would be no skid socks, fall mats and low beds.

Trending:
It has been shown through the data that fall occurrences randomly increases and decreases. With the increases and decreases there is a common trend of the falls occurring during certain nursing hours, this causes the unit to be non-compliant.
Compliance data audit results for moderate sedation procedures from pre to post procedure uncover that most categories met the 90th percentile a majority of the time. This has a direct effect on the provision of care, treatment and services.
Non-compliance regarding the fire drill data occurs on the 2nd and 3rd shifts; this is usually when there is no leadership present on the hospital campus. This would lead one to believe that the staff is only compliant with the drills when leadership is physically on the hospital campus to play “watchdog.” A solution to help this non-compliance behavior is to have leadership present during all hours and complete rounding to ensure staff is compliant with the drills. This is important because the drills have an effect on life safety.
Verbal orders were steady with only a couple of extreme inconsistencies; however there was still non-compliance concerns. This data resulted in an indirect effect on the record of care.
Prohibited abbreviations data revealed that in the 4 units audited the abbreviation “cc” was used significantly more frequently

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