Task 4 final - Accreditation Papers PDF

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Running head: TASK FOUR

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Task Four Mary Ann Cagle WGU

TASK FOUR

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Nightingale Community Hospital (NCH) is preparing for a Joint Commission Survey. A mock survey was completed last month and this report outlines the findings with recommendations for remediation needed to pass the upcoming survey. 1.

Current Compliance Status Meeting Requirements

a.

The following areas of NCH are currently compliant

Accreditation Participation Requirements-meets and performs all required documentation standards for The Joint Commission accreditation participation. Emergency Management-meets standards of responding to concurrent or sequential multiple emergencies and includes an inclusive Emergency Operations Plan (EOP) and an EOP protocol with drills. Human Resources-meet the standards and elements of performance (EPs) that confirm the veracity of staff credentials including orientation, continuing education, continued competency and performance assessments. Infection Prevention and Control-meets standards for an established robust infection control program that is integrated into all hospital departments and uses an epidemiological method of observation, data grouping, analysis, and trending. Performance Improvement-meets standards for data utilization of process improvement measurements and changes based on findings. Rights and Responsibilities of the Individual-meets standards for empowering and improving patients’ participation in their care with full disclosure. This includes patients’ responsibilities to participate as well to enable a full partnership in healthcare.

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Transplant Safety-meets standards for tissue donations and appropriate documentation of any potential infection, or concerns with the transmission of vectors during transportation of the tissue to the transplant site. Waived Testing-meets all requirements for waived (as well as CLIA) testing. b.

The following areas are not currently compliant

Environment of Care-Smoke wall penetration noted; ILSM not initiated during construction; mandatory 18” clearance not maintained in the gift shop; annual testing for medical gas alarm panel not done. Information Management-physician and nurse notes have prohibited abbreviations. Leadership-inconsistent documentation within deadlines; complaints of inadequate staffing. Life Safety-hallway clutter in multiple departments; fire drill process inconsistent. Medication Management-range order not consistently understood and/or followed; unlabeled prefilled syringes in OR/Cath lab. Medical Staff-OPPE process inadequate. National Patient Safety Goals-Universal Protocol inconsistently followed; basins are unlabeled. Nursing - complaints of inadequate staffing; inconsistent documentation and/or assessments. Provision of Care, Treatment, and Services-inconsistent day of procedure reassessment; pain assessment and reassessment inconsistent; missing pre-sedation ASA and absent anesthesia plan in endoscopy. Record of Care, Treatment, and Services-unverified verbal orders by the deadline.

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Out of compliance trends

A cursory overview of the deficiencies shows a correlation between non-compliant findings. a.

Fire drills are required to be held once per shift per quarter. The history of the drills

reveals that the drills were only held approximately once per quarter and not in every department. All departments had only one drill in the last year except for 5E which had two drills. Without formal fire drills the deficits of smoke wall penetration, clutter in multiple areas, and improper storage (greater than 18” from ceiling sprinklers) have gone unnoticed and contributed to the problem. These could have been addressed with regular fire drills. b.

Another area that contributed to multiple correlating deficiencies is nursing

leadership. The Joint Commissions chapter on Leadership discusses the need for creating a culture of safety, planning, and provision of services which include required resources. Nurses vocalized concern about staffing shortages and low morale. Both issues directly correlate to sloppy documentation by using unapproved abbreviations and missing documentation of assessments and reassessments. 3.

Staffing Patterns

Staffing effectiveness is the performance improvement metric utilized for The Joint Commission accreditation for NCH. Staffing patterns on 3 East, 4 East and ICU were measured by comparing and analyzing human resources available with the clinical indicators of pressure ulcer prevention and fall prevalence. a.

Current staffing patterns reveal the following results.

3 East-Oncology department revealed no correlation with the nurse hours including overtime and the fall rate as well as pressure ulcer incidence. Although there is no correlation

TASK FOUR between these indicators, the downward trend in falls may be due to protocol changes of encouraging patients to urinate every two hours. This would decrease incontinence and therefore skin breakdown and decrease the frequency of urgent urination which could lead to falls. Although the ICU incidences for falls and ventilator-associated pneumonia (VAP) have increased y/y there is no correlation between nurse hours, fall incidence and VAP. (Action plans have been established and implemented to decrease falls and VAP.) Analysis of 4 East falls and pressure ulcer tracking reveals an increase in both incidences that correlate to an increase in nursing care hours. Although this may at first appear counterintuitive, the data did not differentiate the increased hours were the result of an increase in personnel or the same number of personnel working overtime. According to Circadian, medication errors and low morale increase as overtime increases.("5 Negative Effects of High Overtime Levels," n.d.) b.

Because of the correlation between staffing and increased falls in 4 East I propose

an alternate staffing plan to decrease patient falls, ulcers and overtime. 4 East is a 20-bed medical surgical unit averaging 96% occupancy. The CNO and Nurse Manager from 4 East will meet with the staffing committee to review current staffing ratios on the floor and compliance with those ratios. Patient acuity, average number of admissions, discharges, and transfers per shift, census, and technical support were considered. The recommended staffing plan will provide a safe staff to patient ratio with appropriate levels of staffing for a 20-bed medical-surgical unit. Texas does not have mandated staffing ratios. Those states with required RN to patient ratios range from 1 RN to 4 or 6 patients for medical-surgical units.("Academy of Medical-Surgical Nurses Hub," 2013)

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Because of the frequency of surgeries during the day shift and admissions during the evening shift, they will be staffed with RNs and PCAs to handle the higher level of care required.. The night shift has less interdepartmental activity and will be staffed with 50% RN and 50% LVN in addition to 2 PCAs and the charge nurse. (See table below.) Managing the nursepatient ratio will not only allow us to maintain accreditation, but it will also provide needed support to our staff as well as decrease the number of patient falls and nosocomial infections.

Beds Shift Day Evening Nights Daily FTEE



20 Charge RN 1 1 1 3

RN 4 4 2 10

LVN

2 2

PCA 3 3 2 8

Total FTEE per Shift 8 8 7 23

In addition to the recommended staffing plan, the Nurse Manager will implement the following:



a policy is recommended to prevent a nurse from working a double shift without a 24hour respite adjacent to the time to prevent burnout and/or excessive fatigue.(Bae, 2012)



the protocol changes enacted by 3 East for every 2-hour voiding should be initiated in 4 East as well.

 Engage the Fall Risk committee for feedback and an action plan for this unit.

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7 References

5 Negative Effects of High Overtime Levels. (n.d.). Retrieved from https://www.circadian.com/blog/item/22-5-negative-effects-of-high-overtimelevels.html?tmpl=component&print=1 AMSN Hub. (2013). Retrieved from https://www.amsn.org/practice-resources/care-termreference/staffing/question-what-suggested-nursepatient-ratio-and Bae, S. (2012, April 2012). Nursing Overtime: Why, How Much, and Under What Working Conditions? NURSING ECONOMIC$, 30(2), 60-71. Retrieved from https://www.nursingeconomics.net/ce/2014/article30026071.pdf Nurse Staffing. (n.d.). Retrieved 01/09/2019, from https://www.nursingworld.org/practicepolicy/advocacy/state/nurse-staffing/...