Current Compliance Status Of Nightingale Community Hospital

Nightingale Hospital complying with Joint Commission’s is not occurring. The Universal Protocols (UP) met on some months and not on others. The Time-Out Hospital Wide UP looks like hospital was increase in compliance over the year and reached the one hundred percent make until December. This protocol should be preform at every surgery or minor procedure (where necessary) according to hospital policy in which involves laterality. The National Patient Safety Goal Data (NPSG) for communication in Hospital Wide Compliance of Reporting Critical Results within sixty minutes met one hundred percent, zero

The general principals for environmental cleaning are to ensure the hospital environment is as clean as possible to reduce the risk of infection, and that all precautions are taken in accordance to legislation and Healthcare policy’s and guidelines. “To prevent the transfer of micro-organisms which may cause infection, and to prevent the transfer of foreign protein which may cause adverse reaction and pose the risk of spreading diseases e.g. vCJD. “

All areas that are being used for healthcare activities should be cleaned with either disinfectant wipes each morning and in between patients/procedures. Equipment should be all new out of the packets and clean. For things more major such as vasectomy’s, minor surgery or family planning clinics, areas should be cleaned everywhere with a disinfectant fluid and also with wipes, gloves should always be worn as well as other PPE such as aprons and hats. All equipment should be new from the packet and only touched by the person who is using

rights, health, and safety of the patient.” This provision, identifying patients, medication safety are related because it is a nurse’s responsibility to protect the patient from harm and promote safety. Nurses are taught to use multiple checks before administering a drug and use two identifiers. These checks include checking the medication against the order when obtaining it, checking again when preparing the medication and the last check is done at the patient’s bedside prior to giving the medication. Also it is imperative to question any medication order that does not seem fit. The order should include a date, time, name of the medication, dosage strength, the route for

The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection

Nightingale is a well establish Community Hospital, which has been servicing the community by providing excellent, and compassionate healthcare provides for their patients’ needs. There values statement pledge to themselves and the community, is a commitment to four core values the first being Safety with the quote “We put our patients first”.

Implementation of patient care practices for infection control is the role of the nursing staff. Nurses are responsible for maintaining hygiene, consistent with hospital policies and good nursing practice on the ward and monitoring aseptic techniques, including hand-washing and use of isolation. It is also in their scope of practice to promptly report to the attending physician any evidence of infection in patients under the nurse’s care and initiating patient isolation and ordering culture specimens from any patient showing signs of a communicable disease, when the physician is not immediately available. Limiting patient exposure to infections from visitors, hospital staff, other patients, or equipment used for diagnosis or treatment and maintaining

The purpose of this document is to provide the management of Nightingale Community Hospital with a resource outlining the current compliance status of the organization based on the Joint Commission guidelines. Based on these guidelines, the Joint Commission will conduct an audit of Nightingale Community Hospital. These guidelines are used to assess the standards compliance in relation to the patient, residents as well as the client care. In detail, assessment and care for patients include execution of a series of processes such as planning care, treatment, provision of care, reassessment of care and discharge planning. Assessment of care is primarily the accommodation of a patient needs while in a care setting. Nightingale Community Hospital is not exempt from inappropriate variations and the current compliance status is wanting. Variations arise from many co related factors, some beyond the control of the hospitals care system. To restore the compliance of the hospital's care system, it is important to review the last survey highlighting the key areas that need restructuring.

Patients want to get attendance immediately. Also, they want health care provider to treat them respect. A concept of the No Pass Zone as a patient experience initiative to provide quick and effective responses to patient’s needs originated a number of years ago from the Hospital Quality Institute (2014). This concept will assist member as needed such as picking up the glasses, reduce the risk and increase the patient satisfaction. An incident report to CHPSO stated a scenario that a custodian passed by a stable, ventilator-dependent patient’s room finding the ventilator alarming rang due to the ventilator tubing had become disconnected but no one responded until he noticed. Unfortunately, no one resuscitated this patient. If the staff could response to this alarm immediately, this patient’s condition would not be deteriorated. This accidence can be avoided. Quickly response to alarm or call bell is not only a safety concern; also it can impact patient satisfaction during hospital

Goal 6: Know Your Alarms. Alarms familiarity on your unit is integral to the best patient safety. Take faulty

This paragraph explains ways to prevent infections contracted from hospitals. The number one way to lower the spread of infections contracted through a hospital is correct sanitation customs. Occupational Safety and Health Administration (OSHA), a federal government agency has come up with guidelines in order to safeguard against the expansion of infections and diseases for patients and the workers (Hedman, 2010). It is mandatory for administrators of hospitals to write a disclosure policy to protect the workers from infections like Hepatitis B and other infections and bad bacteria. Minimizing infections that the workers have can aid in stopping the spread of

The priority nursing diagnosis of hospital acquired infection is risk for any kind of infection. One of the main goals for each patient in the hospital is the patient will remain free of infection as evidence by absence of heat, pain, redness, or swelling in any area of the patient’s body during each nurse’s shift. (care plan book). Frequently hand washing is the best intervention for preventing infection. Hand washing reduces the risk of transmission of pathogens by inhibiting the growth of or killing the microorganisms. (cb)Proper sterile technique during urinary

Research shows that Surgical site infections are preventable. According to the CDC, hand hygiene is the simplest approach to preventing the spread of infections and needs to be incorporated into the culture of the organization. Ensuring the use of infection control prevention is an important component of nursing care. Infection control prevention policies must be communicated undoubtedly to all employees. Staffers who do not comply must be re-educated to ensure that all are complying. Speaking up and pointing out that a nurse forgot to wash his or her hands, or notifying the surgical team that surgical instruments were not adequately cleaned may seem like small issues; but at the same time, not acknowledging a break in a sterile technique could mean the difference between life and death for a patient. One hospital that was struggling with high levels of infection related to surgical procedures, implemented a pre-procedure huddle as a team. This innovate way decreased the spread of infection and was a great way to improve the quality of care for patients. As mandated by the Joint commission, infection prevention personnel should provide multidisciplinary education on SSI prevention, to all team members, including

The CDC has recently proposed two levels of Isolation Guidelines for Hospitalized Patients: Standard and Transmission-Based Precautions.5,6 This new system replaces the previous disease-specific systems and has integrated universal precautions and body substance isolation. Standard Precautions states that blood; all patients’ body fluids (except sweat), secretions, and excretions; mucous membranes; and non intact skin be treated as potentially infectious. The components of Standard Precautions include: hand washing, wearing gloves, wearing mask, eye protection, face shield and gowns when appropriate, cleaning patient-care equipment, enforcing environmental control, cleaning linen, enforcing occupational health and blood borne pathogen protocols

Report for priority focus area under infection control standard, for Nightingale Community Hospital. Our hospital is 13 months away from its anticipated next Joint Commission visit (JAHCO).