Aft2 Task 4

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A1. Status

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

Compliant:
Emergency Management
Human resources
Infection Prevention and Control
Performance Improvement
Right and Responsibilities of the Individuals
Transplant Safety
Waived Testing
Non- Compliant
Environment of Care
Leadership
Life Safety
Medication Management
Medical Staff
National Patient Safety Goals
Nursing
Provision of Care, Treatment, and Services
Record of Care, Treatment, and Services

The hospital has been found to have increase clutter in the hallways, which is a fire hazard and is a safety issue. Nurses were found to be unfamiliar with proper verbal order procedures, how to use the range of orders received and what abbreviations that are prohibited within documentation. The trend shows areas that the hospital needs to implement audits, and education. An action plan will be devised that meets the needs of each unit and areas of non-compliance with proper follow up. In order to be the hospital of choice, administration needs to implement an action plan to address the fallouts. By reviewing non-compliant areas the hospital can assess how to prevent fallouts. Understanding the importance and benefits of The Joint Commission requirements provides the hospital with standards. These standards continue to help the hospital provide the best care.

A2. Non-compliant Trends -

Utilizing the periodic performance review to the fullest allows the hospital to examine areas of non-compliance in comparison to The Joint Commission standards. The hospital found non- compliant trends through out the hospital that needs to addressed:

Policy and Procedure
oAssessment within Same Day Service Areas
Nurses throughout the units are not consistent with assessments and reassessments of patients. A reassessment log will be placed within the patient’s chart that will have to be signed by the primary nurse and co-signed by another nurse. Task reminders will be placed within the computerized charting to prompt nurses to reassess patients.

Proper Documentation
oLack of labeling in various areas
Any specimen sent to the laboratory will be time, dated and double signed by two nurses. The lab will assess for stated information. If not properly labeled the specimen will be sent back to the unit. Any medication not labeled by the pharmacy will require a pre-printed label and double signature by nurses. The patient will mark the appropriate procedure site. The doctor and nurse will then mark the site, in the presence of the patient, with the hospital initials.

Low Performance Scores by the “ORXY initiative”
oEmergency Department assessment and reassessment of pain
Task reminder will be placed within the computerized charting after the charting of any pain medication, to prompt nurses to document pain level before and after administration of medication. oHospital wide use of prohibited abbreviations

Every hard chart will have prohibited abbreviation reminder chart. All charting areas will have posters of prohibited abbreviations. oHospital wide verbal order authenticated
Task reminders will be placed within the computerized charting to remind nurses to authenticate orders. The order will be flagged if not authenticated within the allotted time frame. Charge nurses will be prompted of unauthenticated orders. oHospital wide reporting critical results

Lab results will be flagged and the nurse will be prompted to take action within the computerized charting. The primary nurse and charge nurse will verify all critical...
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