JUNE/JULY 2013 | VOLUME 2, ISSUE 6
Mock Joint Commission Survey... How did we do? Our First Mock Joint Commission Survey Results 6/13 Several common themes were identified during the survey: 1. Infection Control Breaches Restricted areas without proper traffic control Negative pressure rooms – verification of functionality TB patient with room door open for a prolonged period of time Surgical Standards Covering facial hair Standardization of attire Equipment cleaning Dwell times for cleaning wipes General Cleanliness Issues
2. Documentation Issues
1 Min Dwell Time
5 Min for C Diff
Multiple handwriting types on the same form with a single provider signature: Leads to questions regarding the timing of the documentation What may have been added after signature? Forms with blank areas: Consent form for multiple procedures with numerous blank areas – need to mark N/A when appropriate Missing date and time on numerous documents Legibility concerns regarding provider documentation
3. Potential Nursing Scope of Practice Violations Broad dosing ranges with unclear parameters to support nursing decision making: Fentanyl 10 - 75 mcg- titrate to RASS of xx Multiple pain medications with unclear indications to support decision making Tylenol 650mg PO prn pain/fever Percocet ii tabs prn pain Dilaudid 2 mg IV prn pain Nursing writing order and obtaining provider signature
4. Patient Safety in Secure Areas and Monitoring of Restraint Use Allowing access to secured areas: Staff holding door open for pediatric unit Lack of timely response to door alarm in NICU Patient elopement risk in locked psychiatric unit Restraint use Ensure that patient demonstrates a need for restraint Order entry is required in a timely manner!
Respond to all Door Alarms in Secure Areas!
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