Accreditation Audit AFT Essay

A1. Compliance StatusThe ongoing purview readiness audits that atomic number 18 conducted in the infirmary on a daily basis film identified argonas we exit 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 virtually commonly cited by the Joint focusing. Nightingale infirmary has chuck outn to know made great changements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, intercession and Services, Information Management, Handoff Communication and critical value reporting. We lease placed an copiousness of resources and efforts into improvement in these categories and go away continue to make strides to further improve every aspect of the care we provide to our tolerants. (The Joint billing, 2013)A2. Noncompliant TrendsThe expanses we have identified that are not in compliance with the Joint Commis sion standards are1) Environment of care findings with numerous smoke wall penetrations, meanwhile life safely measures for construction projects, blocked fire extinguishers, lack of decent evidence of adequate fire drills, lack of testing for medical gasoline alarm panels, blocked sprinkler clearance as well as make full hallways.2) Falls has continue to be a challenge for our shaping and leave behind continue to be a focus for every department in our hospital.3) Moderate sedation is an area that has been identified that exigencys a hardwired fulfil 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 murder improvement processes to work toward compliance. This standard is a focus for every yardbird and out im mense-suffering department of our hospital.5) Authentication of verbal launchs continues to be monitored, but remains a challenge for our hospital.6) Prohibited abbreviations are used periodi songy throughout our organization and is a piece of our daily audits when performing open record reviews. 7) medicinal drug Management is apriority focus area for our hospital, which we continue to sputter with various elements of this standard. We are focusing in particular on incline order compliance and labeling medications.A3a. Staffing PatternsThe case study shows that on social unit 4E has the most opportunity for improvement in the number of patient travel and hospital acquired compact ulcers. The comparison of falls and nursing care hours appears to be inconclusive, notwithstanding appears to be a trend developing. The data appears that the catering nursing hours per patient twenty-four hours have append during the fourth quarter. In October, the falls per 1000 patient twent y-four hourss was around9. During October, the nursing hours per patient daylight 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 years 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 oblige ulcer prevention follows the same trends.A3b. Staffing PlanThe study has shown that the number of provide available is not causing the increase in the patient falls. The mental faculty are obviously not rounding effectively on their patients, and world 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 effect plan will be evaluated for the remaining second quarter and if successful, will be im plemented 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 Plan1) needful education by 4/15/2014 to all staff on 4E2) All patients will be rounded on hourly get-go 4/16/2014 3) All hourlyrounds will address the 4 Ps (Pain, potty, possessions and situation) a. Paini. Is patient experiencing pain at this cadenceii. If so, ask patient to rate their painiii. Depending on pain level, cover medication or other intervention b. Pottyi. 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. Possessionsi. Is call light, phone, meals, etc within reach of patient? The patient having their possessions within reac h will minimize their need to reach or ambulate without assistance to answer the phone, etc which will prevent fallsd. beati. Is it time to change the patients position (left to right, ambulate, etc) the changing of position frequently will assist in the prevention of pressure ulcers.4) each(prenominal) staff member ta performs the hourly round will muniment each round on the rounding log that will be located in the patient room. Rounds can be done by either the nurse or nurses assistant, as long as all needs for medication or other special(prenominal) needs will be immediately addressed by the nurse. The act 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 wi ll 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 requirement to continue improving the fall and pressure ulcer rate on this unit.B. SourcesNONE