AFT2 T4

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1 AFT2 Task 4 Cassandra Marker Western Governors University Austin Arenz June 27, 2023

2 AFT2 T4 Nightingale hospital has been preparing for our upcoming Joint Commission review. In an effort to have a successful survey, we will undergo a compliance audit to ensure all 18 accreditation standards fall within compliance. For the areas identified as noncompliant, we will evaluate the findings for any noticeable trends and recommend action that should be taken as a result. We will also review the hospital staffing plans to ensure they support high quality care. A1. Compliance Status Below you will find all 18 accreditation requirements and their compliance status for Nightingale hospital. 1. Accreditation participation Requirements has been deemed compliant. By following these standards Nightingale can promote patient safety, work on continuous improvement, standardize best practices, and provide quality care to our patients. 2. Environment of Care requirements have shown noncompliance in EC.02.03.01 smoke walls are penetrated of 1 st and 4 th floor, EC.02.03.03 inconsistent fire drills, and EC 02.05.09 the alarm panel for medical gasses was not tested per policy. 3. Emergency Management has been deemed compliant. By following these standards, Nightingale can effectively respond to emergencies, protect both patients and staff, and maintain a high standard of care during challenging situations. 4. Human Resources has been deemed compliant. By following these standards Nightingale can provide a supportive work environment to its employees, attract as well as retain quality employees, and help assist the facility in regulatory compliance.

3 5. Infection Prevention and Control has been deemed compliant. By following these standards Nightingale helps to protect patients from hospital acquired infections, help prevent the spread of drug resistant infections, and prevent the overuse of antibiotics. 6. Information Management requirements have shown noncompliance in IM.02.02.01 prohibited abbreviations were found on 3E, and 4E, and ICU. 7. Leadership requirements have shown noncompliance in LD.03.06.01 nursing units demonstrating high overtime and low morale. 8. Life Safety requirements have shown noncompliance in LS.03.01.20 clutter in the hallways on 3E, 4E, OR, tele, ICU. LS.01.02.01 no ILSM found for 3 projects. LS.03.01.35 improper sprinkler clearance. 9. Medication Management requirements have shown noncompliance in MM.04.01.01 nurses could describe range dose policy on ICU, and MM.05.01.09 propofol was found unlabeled in OR and cath lab. 10. Medical Staff requirements have shown noncompliance in MS.08.01.01 OPPE process does not meet standards. 11. National Patient Safety Goal requirements have shown noncompliance in NPSG.03.04.01 unlabeled medications and bins found in OR 12. Nursing requirements have shown noncompliance in NR.02.02.01 nurses not documenting in a timely manner on 3E. 13. Provision of Care requirements have shown noncompliance in PC.01.02.03 procedure reassessment missing in cath lab and endo. PC.01.02.07 reassessment missing in the ED. PC.03.01.03 lack of presedation ASA and no documented plan of anesthesia noted in endoscopy.

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4 14. Performance Improvement has been deemed compliant. By following these standards Nightingale hospital drives continuous improvement through data tracking and measured outcomes, which helps to ensure patient safety and allows the staff to deliver high quality care. 15. Record of Care requirements have shown noncompliance in RC.02.03.07 verbal orders not authenticated within 48 hours on tele. 16. Rights and Responsibilities of the individual has been deemed compliant. By following these standards Nightingale prioritizes patient autonomy, patient centered care, protect patient privacy, and patient advocacy. These standards help to empower the patient. 17. Transplant Safety has been deemed compliant. By following these standards Nightingale helps to minimize transplant errors, minimize adverse transplant events, and improve outcomes for both donors and recipients. 18. Waived Testing has been deemed compliant. By following these standards Nightingale ensures proper testing performance, correct usage of testing devices, and minimizes inaccurate testing results or diagnosis. A2. Noncompliant Trends All categories found to be noncompliant will require action to get them to a level of compliance, however two areas appeared to have apparent trends within the facility which identifies a widespread issue in need of correction. The first trend identified was the noncompliance of Life safety and environment of care tied to clutter in the hallways on 3E, blocked fire extinguishers on 3E and 4E, incorrect sprinkler clearance, and lack of fire drills within policy on all units. If the fire drill policy had been

5 followed correctly, with the right number of drills on each shift within each quarter, the items could have been identified and mitigated. This poses a serious threat to emergency responses. These trends may indicate a lack of staffing, poor storage options, or lack of accountability from a leadership level. To correct identified trends, leaders over plant operations, facilities, and EOC must partner with quality and compliance to assess need for policy change, accountability, or process correction. The second widespread trend identified is incorrect abbreviations found in documentation on telemetry, 3E, and 4E. This identified trend poses a high risk for communication breakdown, errors due to similar looking abbreviations, and language barriers that can cause misinterpretation. This is why joint commission has standards set in place to prohibit abbreviations. Because this trend is widespread it is an opportunity for compliance to come up with an education plan for both nursing and physicians to review prohibited abbreviations and implement an auditing action plan to achieve compliance. A3a. Staffing Levels Another area of review for Nightingale is the staffing effectiveness report. Staffing effectiveness can be defined as a satisfactory number of staff that are competent, with different skill levels, that allow the patients to receive safe and quality care. This is measured in both clinical screening indicators and human resource screening indicators. In this staffing effectiveness report, 3 units with a history of challenges were reviewed. 3E and 4E reviewed the prevalence of both falls and pressure ulcers in relation to the amount of nursing care hours that were worked. The ICU reviewed both prevalence and ventilator associated pneumonia with the number of staffing hours worked.

6 The data for ICU did not identify a positive correlation between nursing care hours and fall prevalence. What can be observed is the downward trend of falls over a year period after the implementation of fall investigations, a representative from ICU was added to the fall prevention team, and data sharing started occurring among the care providers. The same can be observed for ventilator associated pneumonias. There was no identified correlation between the nursing care hours and the infections, but there is a downward trend of infections after a bundle was initiated, rounds with the intensivist were consistent, and a mouth care protocol was initiated. On 3E, they identified an issue with pressure ulcers, and to help improve this, sent staff members to educational programs that increased the nurse’s knowledge and awareness of different populations. In addition to educational classes, the unit added a skin care representative to be an ongoing resource for skin care specifically. 3E had intermittent spikes in falls and did end the year with a gradual increase. They did not have additional resources added to specifically target fall prevalence. 4E did identify a correlation in both falls and pressure hours were directly impacted by the amount of nursing care hours worked. Each spike in the amount of care hours worked, has a spike in patient falls in the same month. For the month of February, care hours increased to 13, and falls increased to 5, the next month in March, care hours decreased to 8, and falls also decreased to 2. The yearlong length has multiple corresponding fall patterns. When reviewing the pressure ulcer data, you see may through September sustaining long patient care hours and can see a started upward in pressure ulcers during that time period that remains an upward trend through the end of the year. This review identifies that specifically 4E has not achieved staffing effectiveness and continues to maintain upwards trends in falls and pressure ulcers but has not added any

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7 additional resources in an attempt to improve care. Whereas 3E and ICU continue to see downward trends in most areas that have been given additional focus and resources. A3b. Staffing Plan 4E has demonstrated that it does not have adequate staffing resources to maintain quality care. The proposed staffing model below demonstrates improved staffing with RN’s, Licensed practical nurses (LPN), and certified nursing assistants (CNA). When deciding upon how to allocate staffing resources care was broken out by responsibility. CNA’s can complete daily function tasks such as toileting, ambulation assistance, meal assistance, and hygiene assistance. LPN’s can assist with medication administration, delegated nursing responsibilities, and hourly rounding. The RN’s can complete admissions, assessments, and any additional patient care needs that arise. With additional staff you can allow for each shift to have champions directed towards fall prevention and pressure ulcer prevention, and they can have a skill mix to help support all dynamics. Charge RN LPN CNA 7a – 7p 1 6 3 4 11a – 11p 0 1 1 0 7p – 7a 1 5 2 2

AFT2 T4

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