AFT3 - Grade: A PDF

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AFT3

1. Outstanding Patient Care Issue a. The tracer patient during the survey conducted at the Nightingale Community Hospital made several deficiencies evident. First, the medical history for the 67year-old female patient who was admitted into the hospital was missing. The patient’s medical history contains information such as medication history vital to the patient’s care and must always be collected and reviewed at the time of the patient’s registration. Secondly, the patient did not receive a physical normally required at admission until 72 hours after she was admitted. Unless there is a written evidence indicating that the patient received an H&P assessment within the last 30 days before being admitted into the hospital, which in this case is currently unknown due to failure to obtain patient’s medical history at admission, CMS requires healthcare providers to provide H&P assessments within 24 hours after being admitted and failure to do so is a violation of the CMS’ condition of participation. Another deficiency noted in the survey was failure to update the nursing plan of care after the surgery, which is a failure to abide by standard of care set forth by CMS, which requires healthcare providers to always maintain current patient medical records. Lastly, the tracer patient showed deficiency in nurse’s knowledge regarding range order policy for medication administration. Pain medications must be checked for effectiveness within 1 hour after administration however, documentation shows that a nurse exceed the 1-hour timeframe four consecutive times. 2. Correction Plan a. The tracer patient survey shows Nightingale Community Hospital deficient in the following aspects: H&P requirement, medical records, and medication range order. In reviewing The Joint Commission Manual, MS.03.01.01 EP 6 states that “it is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical (H & P) examinations” [ CITATION His \l 1033 ]. Unlike the CMS H&P timeframe requirement, The Joint Commission has no specific standards pertaining to H&P authentication. Instead, RC.01.03.01 policy states that healthcare organizations are expected to have a clear, written policy that addresses timely entry of information and it cannot exceed 30 days. With that being said, the correction plan to address the hospital’s H&P requirement deficiency, clinical management must create a policy that adheres to both the CMS and The Joint Commission standards. This policy must outline that H&P assessments must be performed within 24 hours of admission unless another H&P assessment that occurred within 30 days prior to hospital admission is present. The policy must also outline as to when the H&P must be authenticated by an authorized healthcare provider (I.e. within 15 days of admission). Additionally, the clinical management must create a review

process that requires clinical supervisors to perform spot checks on H&P assessments to ensure all employees are always following the 30 days/24-hour timeframe. b. Similar to CMS, The Joint Commission requires healthcare providers to maintain accurate and up-to-date medical records that “contain information to justify admission and continued care, support the diagnosis, describe the patient’s progress and response to medications and services”. [ CITATION Rec \l 1033 ]. Furthermore, The Joint Commission manual states that medical records must be “must be organized or accessible in such a way as to allow for timely review” [ CITATION Rec \l 1033 ]. Given this information, I suggest that the hospital follow the following correction plan in addressing their medical record deficiency: i. Create a policy that requires registrars additional and continuous training on the importance of accurate and up-to-date medical records. In addition, the policy must outline a list of information (I.e. medical records, current medication list) that registrars must collect from patients at the time of registration and at every subsequent visits. This policy will ensure that all important information is always collected. ii. Require the clinical team to review collected information prior to seeing each patient. This corrective step is especially important as any changes in the patient’s health such as recent hospitalization, change in medication and new allergies can be found in the medical record obtained by the registrar. iii. Contact the hospital’s EMR provider and request the implementation of system flags immediately. The purpose of the system flags is to remind healthcare providers when important information is overlooked such as missing the 1-hour medication effectiveness check or updating medication information. iv. Lastly, the clinical management must create a policy for continuing education for all staff to minimize complacency. Complacency leads to serious penalties especially in healthcare and the hospital must, therefore, be proactive. c. Lastly, the hospital in deficient in medication range orders. According the MM.04.01.01, there are no Joint Commission standards that prohibit the use of range orders as long as such orders are permitted by the organization’s medication management policy” [ CITATION Med \l 1033 ]. Instead, The Joint Commission allows organizations to determine and implement range orders so long as the organization has a policy in place that outlines, interprets and require staff compliance. Nightingale hospital range order requires staff to review medication for effectiveness within 1 hour of digestion, which is not currently being followed consistently. To resolve this deficiency, I suggest that the hospital implement a corrective plan as follows:

i. Create a policy that requires staff retraining and continuous training on range orders. This will help staff obtain clarification on range orders as well as reinforcements. ii. Request the hospital’s EMR provider to create a reminder for range orders when a medication is entered into the system. This helps minimize confusion as range orders vary for each medication.

Bibliography History and Physicals - Understanding the Requirements. (n.d.). Retrieved from The Joint Commission. Medication Administration - Range Orders. (n.d.). Retrieved from The Joint Commission. Records and Documentation - Format/Availability. (n.d.). Retrieved from The Joint Commission....