...Nightingale Community Hospital Corrective Action Plan In reviewing Nightingale Community Hospital’s Surgical Patient Tracer Worksheet, it has come to our attention that the Primary Focus Area (PFA) in regards to Assessment and Care/Services needs to be addressed immediately. In particular, the nursing plan of care documentation. The nursing plan of care for this particular tracer patient has not been updated since the patient was out of surgery. This lack of documentation, specifically information that has not been updated may place the patient at risk of not providing proper care from the nursing staff. Below is the JCAHO Standard and the Element of Performance where Nightingale Community Hospital may be at risk of being non compliant. JCAHO Standard PC.02.01.03-The standard states that hospitals must provide care, treatment, and services as ordered or prescribed, and it must be in accordance with law and regulation (www. jointcommission.org/). * NNightingale Community Hospital is not completely compliant with JAHCO’s Standard of Element of Performance. The following is the Element of Performance number 7 that needs to be addressed immediately by the Director of Nursing and the Manager of Nursing. * T7. The Element of Performance JCAHO Standard PC.01.03 states that hospitals must provide care, treatment, and services that are based on the most recent patient order(s) (www. jointcommission.org/). Prior to providing patient care, treatment and services...
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...Accreditation audit 4 June 2015 Contents A. Tracer Audit 3 A1. Focus issue 3 A2. Corrective action 4 Works Cited 5 A. Tracer Audit The tracer was performed as part of a process improvement to assess compliance with The Joint Commission standards (The Joint Commission, 2015). In this process, a random patient chart was chosen and the process followed from admission to discharge including any directly related follow-up or readmission. The chart chosen for this tracer was for a 67-year-old female who underwent an open hysterectomy five weeks prior to hospitalization. The patient was admitted for post-op infection, abscess formation and drainage at the surgical site and fever seven days ago. Treatment consisted of surgical collapse of the abscess five days ago and insertion of a central line to accommodate long-term antibiotic usage to ensure non-recurrence of infection or abscess. Several issues were identified in the process of this tracer. 1. History and Physical not performed within 24hrs per guidelines (>72hrs) 2. Lack of documentation regarding function assessment 3. No advanced directive on file and no documentation pertaining to information provision 4. Plan of care not updated post-surgical 5. Pain assessments not being completed or documented per protocol 6. Environment of Care not meeting standards with O2 tanks on floor and air vents dirty 7. Critical values not described as a “read-back” process as per protocol ...
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...Tracer Patient Audit AFT2 Accreditation Audit October 10th, 2014 Tracer Patient Audit With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC. Summary of Tracer Patient Audit Findings This particular survey was conducted concerning a patient that is a 67 year old female, presenting with fever and drainage approximately 5 weeks after an open hysterectomy. The tracer patient was subsequently admitted for a possible postoperative infection. The tracer patient then endured another surgery to treat the infection that started after the original surgery. The patient also received a central line which is used to administer long-term antibiotics. NCH is arranging to discharge the patient to go home with home health, with the aid of her husband, to help administer her antibiotic therapy after discharge. The audit of this particular patient’s care revealed areas that present an opportunity for correction and improvement. Specifically, the patient...
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...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks http://www.homeworkminutes.com/question/view/41054/AFT2-RAFT2-Accreditation-Audit-WGU-MBA-Graduate-Program-Complete-Course AFT2 Accreditation Audit Task 1 1. The purpose of this executive summary is to outline the current status of compliance of the organization for the priority focus area of communication, namely the standard UP.01.01.01 which is named the “Conduct a Pre-procedure Verification Process” as noted by the Joint Commission standards. A.2. The primary area of focus I chose to review was the communication aspect. I feel that communication is vital in any business, especially health care. Clear communication improves patient care and the quality of care. This is evident when time is taken to verify a patient or a procedure. When things go wrong due to misidentification of a patient, not only does that cost time and money for the patient as well as the extra burden of having that wrong fixed, but it also costs the hospitals too. Their costs are increased by trying to fix the issue and then legal issues to follow. The best way to avoid any mistake and/or injury is to adopt a more vigorous verification system. AFT2 Accreditation Audit Task 2 A.1. An unexpected occurrence that involves serious bodily or psychological harm including death or the risk leading to these is known as a sentinel event. (Sentinel event, 2013) A.2. Several people were...
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...Accreditation Audit: AFT2 task 2 1 Accreditation Audit: AFT2 Task 2 Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process. Accreditation Audit: AFT2 task 2 2 Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient...
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...AFT2 Task 1 Christian Fisher Western Governors University AFT2 Task 1 A. Compliance Status During the last Joint Commission survey two years ago, there were several areas of deficiency surrounding the use of moderate or deep sedation or anesthesia. These noted deficiencies gave Nightingale Community Hospital the opportunity to revamp and strengthen our procedures in all areas of peri-operative services. These include the Main OR, CVOR (Cardiovascular OR), Interventional Labs (Cardiac Catheterization and Interventional Radiology), and Endoscopy Suites. Significant process has been made especially in the area of the Time Out. A Time Out is the step by which all work in the particular surgical area halts and everyone in the suite actively participates in ensuring that for the current surgery we have: 1. Correct patient. 2. Correct side and site. 3. Correct procedure to be done. 4. Correct patient position. 5. Correct implants and equipment. All of the Peri-Op services procedural areas brought members of their teams to participate in brainstorming and development sessions in the area of the Time Out to ensure that it was robust and all encompassing. As well, some of these components and other important details should actually be completed prior to the patient’s arrival in the surgical suite. While the Time Out is an effective last act before a surgery proceeds, many other details should and must be completed long before that. This ensures the safety of the...
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...Accreditation Audit AFT2 Task 1 Executive Summary Current Compliance Status A. Compliance Status – Executive Summary Nightingale Community Hospital’s is a healthcare facility with a vision to” be the hospital of choice for patients, employees, physicians, volunteers, and the community.” We also state our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Creating this vision and staying true to the stated mission requires that we adhere to the requirements set forth by the Joint Commission. In preparing for the Joint Commission visit there are focus priority areas that will need to be addressed if Nightingale is going to be compliant. The specific focus area addressed in this summary is medication management. There are three standards that come under the medication management area. The standards are listed in the table below along with their descriptions and summary of whether Nightingale Hospital has the documentation/data to be Joint Commission compliant for the given standard. Standard | Description | Joint Commission Compliance | MM.01.01.01 | The hospital plans its medication management processes. | MetNightingale PoliciesPatient Care Polices: 1. Medication Management, Patient Specific Information 2. Medication Administration | NPSG.03.04.01 | Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. | MetNightingale Hospital...
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...Accreditation Audit (AFT2) Task 2 Sentinel Event Western Governors University Accreditation Audit (AFT2) Task 2 Sentinel Event A1. Sentinel Event Summary This sentinel event is directly associated with a child abduction at Nightingale Community Hospital. A 3 year old patient was having surgery at Nightingale Community Hospital on Thursday, September 14. The patient’s mother accompanied the patient before surgery and completed all consent form. An estimated time of 1 hour 45 minutes was given as the time to complete surgery and recovery. The mother informed the pre-op nurse that she would be off campus during the surgery and would return to pick up the patient in the time frame given. She also provided a phone number to contact her if the procedure was finished earlier than planned. Upon completion of surgery and recovery, the patient’s mother was paged from the waiting area by the recovery nurse. The mother was had not returned to the hospital at this time. The patient care was then transferred to the discharge nurse while waiting for the mother to return. During this time the patient was very upset and crying for her mother. The discharge nurse was notified that the father was in the waiting area and approved for the father to see the patient. The father was with the patient for about 30 minutes and the mother had still not arrived. At that time, with no specific information about the patient’s custody arrangement, the discharge nurse provided the father...
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...Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis A. Aspects of Root Cause Analysis 1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy...
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...AFT2 Accreditation Audit – Task 2 Western Governor’s University AFT2 Accreditation Audit – Task 2 Nightingale Community Hospital is a healthcare facility that prides itself on being a hospital of choice within its community by being a leader in providing high quality healthcare. The first of Nightingale Community Hospital’s value statements addresses safety. A key aspect in providing safe patient care includes communication among caregivers. A1. Sentinel Event Nightingale Community Hospital recently experienced a sentinel event that involved the possible abduction of a 3 year old patient. As defined by the Joint Commission (2014), a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. On September 14th a 3 year old patient came to the hospital for an outpatient procedure. She was accompanied by her mother. They first registered for the procedure and completed all required registration documents including authorization forms. The patient then went to the pre-op area to complete all pre-op assessments. At this time the mother informed the pre-op nurse that she had to take care of a personal matter with her son while her daughter, the patient, was in surgery. The mother gave her contact information to the pre-op nurse who then recorded it in her personal notebook. From the pre-op area the patient was then taken to the operating room. Both nurses and surgeons are present during the...
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...AFT2 – Task 1 2/4/2014 Nightingale Community Hospital (NCH) is a 180-bed hospital, acute care, not-for-profit hospital that prides itself in quality healthcare. In thirteen months, NCH will face their next Joint Commission audit, and based on current findings and statistics they will need to make some adjustments to be compliant. While Joint Commission will address all the Priority Focus Areas: Infection Control, Communication, Medication Management, and Information Management, this summary will concentrate on areas in the Communication area that are lacking. A. Compliance Status UP.01.01.01: Conduct a preprocedure verification process – This Element of Performance is in place to ensure that a hospital is always performing procedures on the right patient. 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Nightingale Community Hospital currently has a written policy to conduct a preprocedure verification and a Preprocedure Hand-Off form to ensure information is communicated; however, there are areas lacking in the hand-off form. Although the current hand-off form has an area to verify the patient identification/armband and if the site has been marked, there is no area to verify the patient procedure and the procedure site thus leaving the hospital not in compliance with the standard. 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability...
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...------------------------------------------------- Task 1: Executive Summary Assessment Code: AFT2 Executive Summary: Nightingale Community Hospital Joint Commission Compliance Standards for Communication Focus Area Recently there has been much media focus on preventable medical errors. Any google search will produce a multitude of news articles that all report that preventable medical errors is now the third leading cause of death in the United States. Poor communication plays a role in most if not all of these errors. In fact the Joint Commission (2012) has published that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. While communication errors are not the sole cause, they certainly contribute to the problem and must be a consideration in every patient safety program. One particular area of preventable medical errors involving communication errors that has received widespread media attention is wrong site surgery. Chassin (2013) reported that wrong site or wrong person surgery occurs an estimated 50 times weekly in the United States. This number is hard to judge exactly as not all states mandate reporting, but the fact remains that wrong site surgery continues to occur despite concerted efforts to prevent it. All hospitals to include Nightingale must continue to place emphasis on preventing these errors. Nightingale has wisely chosen to focus on this area for the upcoming Joint Commission...
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...Accreditation Audit AFT2 Task 1. Herman Big Mawanda Western Governors University Contents COMPLIANCE STATUS. 3 PLANS OF COMPLIANCE 7 JUSTIFICATION 8 BIBLIOGRAPHY 10 Nightingale Community Hospital provides leadership in quality health services. Its core values focus on safety, community, teamwork and accountability with a vision of being a hospital of choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the...
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...AFT2 Task 2 A1. Summary of Sentinel Event A recent sentinel event occurred at Nightingale Community Hospital involving the possible abduction of a 3 year old patient. According to the Joint Commission, a sentinel event is one that is unexpected and results in death or serious injury (2015). According to the documents and interview provided, a child Tina was admitted into the hospital on September 14th by registration. Insurance and demographic information was collected by registration. The patient then went to pre op with his mother for outpatient surgery. The pre op nurse then prepped the patient for surgery by having the mother sign the consent form, changing into appropriate surgical attire, and starting the I.V. The pre op nurse told the mother the procedure would take about 45 min and then the patient would be in recovery for at least an hour. The mother had to leave to take care of an errand with her other children and had left her cell phone number with the pre op nurse. She instructed the pre op nurse to call her if her daughter was done sooner. The pre op nurse put down her number in her notebook. After the completion of the surgery, the patient was taken to the Post Anesthesia Care Unit (PACU). Upon arrival in PACU, the mother had not returned. The patient was becoming uneasy that her mother was not back, the PACU nurse had the mother paged on intercom but it was determine that she had not returned. The patient was then transferred to the discharge nurse who was...
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...Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol. Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance...
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