Accreditation Compliance

Compliance Status

Nightingale Community Hospital was recently under inspection to test its compliance

with the Joint Commission standards. These standards are set to guide any given facility a clear

direction to providing extraordinary care to all patients. The guidelines can be implemented

almost as a checklist to ensure that patients get the desired treatment but also for the hospital to

run as efficiently as possible. While there was a great deal that was up to the Joint Commission’s

standards there is a list of issues to correct. There were a total of 34 infractions found during the

assessment. Record of Care was the most frequent finding with six infractions. This was

followed by the trio of Environment of Care, Life Safety, and Provision of Care all coming in

with five findings each. The highest performing of the accreditation functions was the Nursing

Leadership and Medical Staff with only one finding apiece.

Within the Record of Care there were numerous issues to amend. Verbal orders were not

authenticated within 48 hours five times. This was the only infraction of this nature but is the

most frequent of any infraction. All were shown to be found during chart reviews during periodic

performance review rounds and performance improvement audit. Another issue of concern is

that this was not a single location, but rather in five separate locations throughout the hospital. It

is unclear of the time frame these findings were committed so that will need further review. If

this was found looking into the last years’ worth of records then it is not a debilitating issue. It

would be a small percentage of the total volume of verbal orders given in a year, but if within a

day or week this would be cause for concern.

Environment of Care was cited for five findings for a lack of compliance. Two of these

were different floors smoke wall penetrations. One the first floor it does not indicate the exact
number but states there are more than three. These are fire/smoke risks and should be a top

priority to repair as they are major patient safety risks. The Interim Life Safety Measure's

guidelines were not initiated during three of the last construction projects. While not specifically

stating what the issue was, this could have been a risk such as not having a fire watch while the

fire alarms were disconnected during construction. This is an example of an unnecessary risk that

was taken without major incident, but is something that should never be overlooked again. A

master alarm panel for medical gasses was not checked as often as was needed, which can be an

immediate risk to the patients and faculty. If it has not been done within the recommended time

frame this is a priority to have done as well. The sprinklers in the gift shop also did not have the

minimum clearance of 18 inches as well. Either the sprinklers must be elevated or the closest

items will need removed or lowered to allow at least 18 inches. Being too close to the sprinkler

causes the spray to be obstructed and decreases its effectiveness.

Also spread throughout the hospital were Life Safety violations. There were clutter in

hallways in four areas of the hospital. Both 3E and 4E had fire extinguishers blocked and linen

carts stored in the hallways. There were also mobile computers and medical carts in 3E’s

hallways, while both should be in designated areas. The OR had stretchers and surgical

equipment in the hallway. Notes do not readily indicate if the surgical equipment were sealed in

sterile bags or not, but contamination is a risk that is being taken if they are not. Finally the fire

drill process and the frequency of fire drill participation are both inadequate. These put the

patients and staff both in danger every day they are lacking.

Nightingale has issues in regards to its Provision of Care, Treatment and Services. The

Day of Procedure Reassessments were missing multiple cases in the Cardiac Cath Lab,

Endoscopy and Surgery Pre-Op. If there is a change of condition then this could mean the
treatment(s) might be unnecessary or inadequate. The ED also has a count against them for

consistently missing pain assessments and reassessments for the patients going through. The

reassessment is critical for pain management. It is what allows the physicians to know if the

treatment is working, ineffective or even having adverse effects. Endoscopy also is failing to

meet the ASA guideline and even fails to note a plan for anesthesia for the endoscopy. Failing to

do so is a dangerous practice for the patient.

Four counts were found against the accreditation function of Information Management.

While these were across four separate departments they were all for the same reason. Each of 3E,

4E, ICU and Telemetry were found using prohibited abbreviations. Acronyms must be approved

for use before they can be used in any of the notes for a hospital. Many are prohibited due to the

possibility that they could be misunderstood. IU means “international units” but could be

mistaken for IV (intravenous) or even the number four being written in Roman numerals.

Medication management was found to be the root of three findings. In 4E the nurse did

not follow the range order policy while the nurse in ICU could not explain how to use the range

order. For something as strong as powerful pain medications this can be dangerous. A range

order is the scheduled frequency and dose a medication is allowed to be administered. This can

vary greatly based on factors such as the patient’s age, weight, and medical history. Not

understanding how to use this means after the physician has prescribed a drug that it could be

administered incorrectly. If that is a powerful opioid it could cause adverse effects up to fatality.

The OR had Propofol syringes that were not labeled. Any instance a medication is not labeled is

a chance it could be used incorrectly. This is a potentially fatal error that is completely

preventable as well.

Universal Protocol was found to have two failings. The first being in Endoscopy when
they Broncoscopy site was not marked appropriately. Only a select number of procedures are

able to be done without being marked to prevent procedures from being done on the incorrect

site. OR made the same mistake on a patient’s knee arthroscopy. If the incorrect site would have

a procedure done on it then the facility would be subject to lawsuits for putting the patient

through unnecessary pain. The surgery could also have lasting negative effects as well if the

surgery would cause permanent damage.

The OR had two findings that no other department had. They failed to meet the

guidelines for the National Patient Safety Goals. The basin was noted to be left without a label

and they had pre-labeled syringes in cataract packs from an external supplier. These are risks that

can have tragic consequences if medications we mislabeled in some way. Failing to assure these

are done correctly is neglecting the patient’s safety.

Medical staff had only a single error to correct. Their Ongoing Professional Practice

Evaluation was not up to the Joint Commission’s standards. That practice is to ensure

practitioners are performing at an acceptable level. While doing so it can help discover trends the

practitioner needs to correct, if the practitioner is providing quality care and to ensure

practitioners are able to be confronted with data showing their performance is lacking. This also

allows the medical staff to allow or disallow privileging for specific clinical activities.

Nursing and Leadership was the final department with a single finding. In 3E the nurses

consistently fail to document in a timely manner. They claim to be “too busy” and has resulted in

low morale and necessitated overtime. Upon further discussion it seemed both the staffing

pattern and nurse-to-patient ratio were inadequate. If the staff is overworked and has low morale

then the quality of their care is bound to suffer. If these issues are happening there may be a

considerable failure in one or more leadership positions. Until this gets fixed the patients are
unlikely to get the care they deserve or that the Joint Commission would approve.

All of these issues need corrected. They are not frivolous rules by individuals who have

lack any credible work history in the field. Meeting the Joint Commission’s guidelines ensures

excellent patient care, safety, and provides framework for the facility to be run at a high level.

Many of these standards are not only their own, but also ensure the facility is meeting state or

federal demands as well. Having these standards also allows the facility to have a baseline to see

where issues are and where the potential for improvement can be found.

Case Study Trends

Several trends throughout the FSA Findings are evident. Clutter in the hallways was

noted in four separate departments. Some of these were even blocking fire extinguishers.

Prohibited abbreviations were also found being used in three departments. With the nurses in 3E

having multiple issues with documentation and still requiring overtime there are issues in

leadership and in the general level to correct.

The Pain Assessment document shows that PACU is successful with pain assessment

audits an average of 96.67% of the time. By comparison PACU is very successful to the other

two departments that have data present. 3E was over 3% lower than PACU at 93.5% success rate

over the course of the year. Finally ED only reported an average of 70.67% success rate. While

the goal is 100% for each there must be some level of allowed deviance. For example, adult

patients can choose to leave the ER at any point and may do so before the pain assessment or

reassessment. Or if someone goes to ER and suddenly needs to be moved to an emergency

surgery or become an inpatient. With the high turnover and sometimes rapid pace they should

have the highest deviance allowance. But even then it should be no more than 3-5% off of the

desired 100%. Both 3E and PACU should be able to maintain a 99% rate most months, there
being few reasons not to do a pain assessment. Doing the pain assessment is a standard protocol

that should be done for every patient.

Within the Endoscopy Department there are several points worth noting that falls in line

with the FSA Finding report. They had a finding stating there was a lack of documentation for

plan of anesthesia and pre-sedation ASA. This falls in accordance with the Moderate Sedation

Audit. In the Pre-procedure section the quarterly reports show a 79.5% average for both ‘ASA

determined’ and ‘sedation plan documented.’ That is a sub-standard percentage and is evident to

why the finding was made. Other than having the exact same numbers as the Mallempti

Classification complete the rest of the pre-procedure tasks were performed at a much higher rate.

The other two findings in the FSA were side not being marked for the lung biopsy and a lack of a

consistent process. The reassessment shows a total average of 86.75% success rate, which again

is still too low.

Nightingale is lacking in their adherence to their fire drill protocol. The guideline set was

one drill per shift per quarter. The only quarter this guideline was met was the second quarter.

The third shift was not put through the fire drill in the first and third quarters. During the fourth

quarter the second shift was without a drill. These should be scheduled prior to the first of the

year by the head of security or whoever has been assigned to run the drill. One of the most

prudent choices would be to look at where the highest number of patients to evacuate. Both 3E

and 5E have had two drills scheduled. That means the next two most populated departments

would be best served with another drill each.

While looking at only two prohibited abbreviations in the 3E, 5E, ICU and Telemetry

departments there was a large number of findings. While “cc” was used far more often than “qd”

it was also far less consistently used. The four departments had a variance of up to 27 between
two months while using “cc” compared to only 15 with “qd.” It is unknown if there were

meetings or emails where the improper abbreviations were being advised to not be used but

trends indicate there might have been. The number of times “cc” was used rose through April

and was nearly halved in May. It then steadily climbed through September but gradually went

down. This may indicate that a notification when out after April and then again after September.

To remedy this these actions should be noted by individual department and logged by the

individual making the infraction. With the data present it is unknown if a few individuals are

making the mistake repeatedly or large amounts of people are making the mistake only a few

times a year. With so many instances being found for just these two abbreviations it is surprising

for only four findings in the FSA audit.

Verbal order authentication has had a varied, disappointing compliance history. This

lower turnout is throughout the entire hospital. The best month of compliance was in March with

90% compliance. The lowest level of compliance was in August with only 60%. That poor

month helped lead to the third quarter being the lowest at an average of only 73%. This is unlike

March’s effect on its quarterly rating. The drop in February caused the quarter to drop under the

second quarter average of 87%.This seems fitting that once finding was found in four different

departments in the FSA audit.

Staffing Pattern

Three units were reviewed for fall prevalence and pressure ulcer prevalence. Numbers

were scattered and only one floor seems to make a definitive trend noticeable. But these are

general numbers that can have a multitude of implications depending on the details behind them.

In 3E there has been a slight drop in falls due to improved training a regulation of the nursing

staff. Being more proactive in getting their patients to the restroom has allowed the patients to
rush less often. Being more controlled has been thought to help with their fall frequency. Being

up more often has also been tied to the reduction of pressure ulcer prevalence for the patients as

well. While the nursing hours fluctuated there was no direct correlation readily evident to fall

frequency. In November the hours took a notable spike and the falls dropped dramatically. In

May the hours peaked to the same amount but the fall count was the highest of the year.

In 4E the number of hours seem to correlate to the number of falls the patients

experienced. The peak months of the year showed the falls to rise accordingly, while the falls fell

along with the hours dropping. This seems entirely counter-intuitive to the expected results.

Meanwhile the number of pressure ulcers did not show any correlation to the number of hours

the nurses worked. It is worth noting that the grouping of pressure ulcers were clustered all in a

five month period. No ulcers were found at all in 8 of the months, but in four of those five there

were multiple each month.

Fall prevalence in ICU was also seemingly unconnected to the number of nursing hours.

September had a dramatic spike in falls while nursing hors dropped. At near the same number of

nursing hours the ICU had zero falls in six months total. The ICU was the single department with

ventilator assisted pneumonia, but again there was no obvious correlation. There were two

months of approximately 20 VAP each, but no other cases over the remaining 10 months. These

were spread out as well, and the hours relatively consistent throughout the year.

While the data presented does give a general glance at the nursing hours in comparison to

the issues at hand there is a great deal of information lacking. What shifts are the falls happening

in? Is there an obvious catalyst for the fall? If a patient happens to fall at night after the floors are

still wet from being mopped then that may not be able to tie in with the nursing hours. But if the

nurses are being forced to work more overtime or longer shifts to cover for others on vacation
then they will experience more difficulty. The hours per day need to be examined and the

number of nurses active per shift as well. Having eight hour shifts with two nurses per shift will

likely have less falls than six nurses working 12 hour shifts. The longer shifts allow employees to

become tired and distracted near the end of their shift. The rank and experience levels of nurses

may have an indication as well. Nothing in the graphs indicates that all were registered nurses.

The Effectiveness Report actually leads to believe there might be a range of nurses when it says,

“skill mix in staff relation.”

The pressure ulcers may have to do with staffing and practice. Since there was a cluster

of them over a few months it may have been due to a new hire or loss of a veteran nurse. Patient

status could have been in question as well. If patients had conditions limiting their mobility more

frequently in those months then the numbers could have spiked as a result. Their medical

ailments not causing hospitalization could have had a direct result too. Diabetes is such an

example as it causes wound healing to slow.

With the VAP being solely in two months it leads to question what factors caused it.

Pneumonia is contagious so it may have started with one person and been passed multiple times

before enough sterilization was done to exterminate the infections. Knowing it is contagious is

not indicative of how it was passed between patients. It could have been in a single room that

was poorly cleaned. The bacteria could have been in a machine the patient was using that was

not sterilized properly.

Staffing Plan

Patient safety is of the highest priority for a hospital. For the nurses to better protect the

patients there are several changes to implement. Shifts should average eight hours per nurse, with

a maximum of 12 hours. The 10 and 12 hour shifts should be rare and of the nurse’s own choice.
Having shorter hours makes it easier for the nurses to focus and be vigilant for potential risks to

their patients. The shorter shifts should aid in preventing burnout and job dissatisfaction. This

could potentially retain the top nurses and make Nightingale a premier location for the best

nurses to work. Many hospitals run predominantly on 12 hour shifts for nurses. Being able to

spend more home time with their families is a fantastic benefit and will help to ensure they value

their job.

After analyzing when the falls have happened there should be preferential scheduling to

address the issue. If the 75% of the falls happen between 7am and 4 pm then staffing should be

slightly weighted to that shift. If there were an average of 10 nurses in each of the shifts then

pulling one from each of the other two shifts would be best. This would put 12 nurses during the

high-risk shift and nine on the two lower risk shifts.

In the Staffing Effectiveness report it was mentioned that numerous nurses in 3E attended

the NICHE program. This was thought to aid them in awareness and education for patient safety.

This should be a mandatory program during orientation. During their shift, once per year, there

should be a refresher course. Going through all fall-related reports from the last two years or

more should show trends. Maybe the falls were frequently due to cluttered hallways. There were

four findings for this in the FSA Finding report so that is a distinct possibility. These risks should

be tallied and part of the orientation and refresher courses. Aside from the NICHE program a

standardized program should be implemented like the Morse Fall Scale.

While these actions should decrease the number of falls it will not eliminate them

entirely. When they do happen immediate action should be taken. The nurses should have a

huddle during each shift. The falls should be analyzed, and it should be discussed thoroughly on

how to have prevented the fall. This will lead to better ability to spot these risk factors in the
future. If this also requires a change in the normal work flow then that should be made

abundantly clear.