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Discuss the current compliance status of the healthcare facility.
Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas:
Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All
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According to PC.03.01.03 from The Joint Commission states; the hospital is to provide the patient with preprocedural treatment and services according to their plan of care. The licensed practitioner is to plan or agree with the plan for sedation for each patient.
Accreditation function of universal protocol looked at two sentinel events where the sites were not marked. First, no site marked in endoscopy with the bronchoscopy lab lung biopsy. Second, no site marked in OR for a knee arthroscopy. Marking the site before the surgery insures that you are doing the right surgery on the right site of the patient. This is a good form of communication for the whole team.
Accreditation function of National Patient Safety Goals (NPSG) it was observed during rounds that the OR had unlabeled basins. All containers containing any type of medication or solution needs to be labeled at the time it is placed inside the container. If it is not labeled medications and solutions are to be discarded immediately. It was also found in the OR that they were using pre labeled syringes. NPSG.03.04.01 states to label all each medication or solution as soon as it is prepared.
Discuss any trends evident in the Accreditation Audit Case Study - Task 4 Artifacts that may cause the organization to not be compliant with the Joint Commission standards for patient care.
Fire drill history shows that none of the areas in the hospital have been compliant with drills. Nightingale Hospital

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