Accreditation Audit AFT

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29 February 2016

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A1. Compliance Status

The ongoing survey readiness audits that are conducted in the hospital on a daily basis have identified areas we will focus on to ensure that our accreditation survey results are exceptional. Audits are performed on an ongoing basis with a focus on trends that are most commonly cited by the Joint Commission. Nightingale hospital has proven to have made great improvements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, Treatment and Services, Information Management, Handoff Communication and critical value reporting. We have placed an abundance of resources and efforts into improvement in these categories and will continue to make strides to further improve every aspect of the care we provide to our patients. (The Joint Commission, 2013)

A2. Noncompliant Trends

The areas we have identified that are not in compliance with the Joint Commission standards are:

1) Environment of care findings with numerous smoke wall penetrations, interim life safely measures for construction projects, blocked fire extinguishers, lack of sufficient evidence of adequate fire drills, lack of testing for medical gas alarm panels, blocked sprinkler clearance as well as cluttered hallways.

2) Falls has continue to be a challenge for our organization and will continue to be a focus for every department in our hospital.

3) Moderate sedation is an area that has been identified that needs a hardwired process for not only the hospital but for the anesthesia providers. The Joint Commission standards for moderate sedation compliance will require teamwork from the hospital and anesthesia group.

4) Pain assessment and reassessment is an ongoing primary focus area that we have not mastered in our organization. We have developed performance improvement processes to work toward compliance. This standard is a focus for every inpatient and outpatient department of our hospital.

5) Authentication of verbal orders continues to be monitored, but remains a challenge for our hospital.

6) Prohibited abbreviations are used periodically throughout our organization and is a piece of our daily audits when performing open record reviews. 7) Medication Management is a priority focus area for our hospital, which we continue to struggle with various elements of this standard. We are focusing in particular on range order compliance and labeling medications.

A3a. Staffing Patterns

The case study shows that on unit 4E has the most opportunity for improvement in the number of patient falls and hospital acquired pressure ulcers. The comparison of falls and nursing care hours appears to be inconclusive, however appears to be a trend developing. The data appears that the staffing nursing hours per patient day have increase during the fourth quarter. In October, the falls per 1000 patient days was around

9. During October, the nursing hours per patient day were approximately five. November shows an increase in falls per patient day to 11.5 with nursing hours per patient day of 15.5. December continues the trended increase to 15 falls per 1000 patient days and 15 nursing hours per patient day. The data shows that the more hours per patient day we have, the more falls per 1000 patient days we experience. The data for pressure ulcer prevention follows the same trends.

A3b. Staffing Plan

The study has shown that the number of staff available is not causing the increase in the patient falls. The staff are obviously not rounding effectively on their patients, and being proactive in fall prevention. The plan to decrease nosocomial pressure ulcers and prevent falls will be presented to all staff on 4E by 4/15/2014 and fully implemented immediately. The new action plan will be evaluated for the remaining second quarter and if successful, will be implemented throughout the organization. The plan will utilize 10 hours per patient day, which is the average of the last quarter. The plan will require the staff to be more efficient and round with purpose in order to stay focused on the needs of the patients. This increased focus should prove to decrease the number of falls per 1000 days.

Action Plan:

1) Mandatory education by 4/15/2014 to all staff on 4E
2) All patients will be rounded on hourly beginning 4/16/2014 3) All hourly
rounds will address the 4 P’s (Pain, potty, possessions and position) a. Pain
i. Is patient experiencing pain at this time
ii. If so, ask patient to rate their pain
iii. Depending on pain level, offer medication or other intervention b. Potty
i. Does the patient need to use the restroom, urinal or ambulate to bathroom and if so, assist them to prevent falls and stay with them until completed c. Possessions
i. Is call light, phone, meals, etc… within reach of patient? The patient having their possessions within reach will minimize their need to reach or ambulate without assistance to answer the phone, etc… which will prevent falls

d. Position
i. Is it time to change the patient’s position (left to right, ambulate, etc…) the changing of position frequently will assist in the prevention of pressure ulcers.

4) Each staff member ta performs the hourly round will document each round on the rounding log that will be located in the patient room. Rounds can be done by either the nurse or nurse’s assistant, as long as all needs for medication or other special needs will be immediately addressed by the nurse. The action plan presented will ensure that the patients are seen and their needs are met on an hourly basis. The staff will anticipate the needs of all patients by addressing the areas that cause the majority of falls. The patients will know the staff will be returning within an hour and will no longer have a need to utilize their call light unless in an emergency. The call lights will decrease, which will create a more organized unit that is very focused on being proactive with all patients. The results will be evaluated and changes and update to the plan will be made where necessary to continue improving the fall and pressure ulcer rate on this unit.

B. Sources

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"Accreditation Audit AFT" StudyScroll, 29 February 2016,

StudyScroll. (2016). Accreditation Audit AFT [Online]. Available at: [Accessed: 5 December, 2023]

"Accreditation Audit AFT" StudyScroll, Feb 29, 2016. Accessed Dec 5, 2023.

"Accreditation Audit AFT" StudyScroll, Feb 29, 2016.

"Accreditation Audit AFT" StudyScroll, 29-Feb-2016. [Online]. Available: [Accessed: 5-Dec-2023]

StudyScroll. (2016). Accreditation Audit AFT. [Online]. Available at: [Accessed: 5-Dec-2023]

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