Mock Survey Executive Sponsor For Level 1 Findings ✓ Solved

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Mock Survey Exec Sponsor For Level 1 Findings 20171standard Ep

Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report Out to Reg Steering Date Standard EC.02.02.01 The [organization] manages risks related to hazardous materials and waste. Note: Hazardous energy sources include, but are not limited to, those generated while using ionizing or non-ionizing radiation equipment and lasers. (EC.02.02.01 EP 5 finding in 2015) EP 12 The hospital labels hazardous materials and waste. Labels identify the contents and hazard warnings. Footnote: The Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens and Hazard Communications Standards and the National Fire Protection Association (NFPA) provide details on labeling requirements. Containers used to transport soiled instruments in the ED, OB, and ICU did not have biohazard labels. At times these containers are left unattended in dirty utility rooms or at the nursing desk for pickup. 6/24/17 Standard EC.02.04.03 The [organization] inspects, tests, and maintains medical equipment. (EC.02.04.03 EP 3 finding in 2015) EP 5 The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented. The insert for residual chlorine testing was not available to determine if once packaging is opened a do-not-use-after date should be applied in dialysis. 5 bottles of chlorine testing strips in dialysis had manufacturer’s expiration dates of 1/16. Another bottle that was open had an open date but no do-not-use-after date on the bottle. It was not clear that the staff nurse interviewed had knowledge of the 3-month expiration date once the container was opened. 6/24/17 Standard EC.02.05.01 The hospital manages risks associated with its utility systems. EP 15. In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies, humidity, and temperature. (See also EC.02.06.01, EP 13 and EC.02.06.05, EP 1.) Note: Areas designed for control of airborne contaminants include spaces such as operating rooms (all Classes), special procedure rooms that require a sterile field, caesarean delivery rooms for The door between the clean and dirty rooms used to process TEE scopes was left open. This defeats the ability to maintain the proper pressure relationship between these rooms. There were exterior shipping cardboard boxes stored in the room used to store scopes. Due to the particulate matter in cardboard, these should not be left in a room where sterile supplies are kept. (Note: This could be scored at IC.02.02.01. EP 4). The room used to clean soiled ventilators and perform pasteurization of sleep lab masks 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings patients diagnosed with or suspected of having airborne communicable diseases (for example, airborne infection isolation rooms, rooms for patients with pulmonary or laryngeal tuberculosis, bronchoscopy, patients in "protective environment" rooms [for example, those receiving bone marrow transplants], laboratories, pharmacies, sterile supply/processing rooms and other sterile spaces). The basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the facility, based on the edition used at the time of design (if available). was positive to hall; closing the door between this room and the room used to store clean ventilators did not affect the pressure relationship. A process to assess bronchoscopy performed in non-negative rooms could not be described. Please see – Standard EC.02.06.01 The hospital establishes and maintains a safe, functional environment. (EP1, EP 26 Finding in 2015) EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. In the ED, the BH rooms have beds that have ligature risks. The doors also open inward, providing a barricading opportunity. In the ED, the shower used for BH patients has multiple ligature risks. The shower itself has a long metal coil attached to the shower head that could be used as a ligature. Behavioral Health – Doors in the BH unit open inward creating a barricading opportunity. The unit is working on a solution at this time. Not all screws in the patient rooms are safety screws. A number of ligature hazards were noted in patient rooms such as wall lights and sink handles. Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard IC.02.02.01 The hospital implements infection prevention and control activities when doing the following (EPs Survey Finding) EP 2 The hospital implements infection prevention and control activities when doing the following: performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.* (See also EC.02.04.03, EP 4) Note: Sterilization is used for items such as implants and surgical instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes. The GlideScope stylet was not cleaned according to IFU in the ED; staff appeared unaware of the instructions. The process to initiate cleaning of soiled instruments outside of the OR was inconsistent and not in accordance with the recent CMS response. Some areas did not start the process, staff could not speak to opening the instruments, the process when started was not consistently at the point of use and it was unclear if the instruments remained wet. In the one department the instruments were wiped with san-wipes creating a safety hazard for staff. Areas reviewed were the ED, ICU MIC, and Wound Care. In review of the process used to disinfect TEE scopes, it was noted that some of the process steps were not documented as completed per hospital policy (missing initials of the operator and the number of the transducer on the leak tests). Staff did not know whether the solution used in the process to disinfect TEE scopes was outdated; it was dated April 2017 and the insert was not available. In the ENT clinic, the IFU for the flexible scopes was not available. Staff could not answer whether the IFU requires manipulation of the tip of the scopes while performing the leak test. Staff in the ENT clinic should be documenting 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings the lot numbers of both the chemical disinfectant and the indicator strips. Follow-up needed – In reviewing the IFUs for the thermal probes used with the ventilators, they appear to indicate that they need sterilization. The infection prevention specialist should review this issue. The organization currently cannot track surgical instruments back to the patient. A surgical instrument tracking system is on the capital budget request list. Recommendation – In areas where high-level disinfection and/or sterilization occur, it is recommended that posters be used in these areas. These assist staff and are helpful to staff when speaking to surveyors. Some areas had posters but some did not. Since Cidex is no longer used to disinfect vaginal probes, the Cidex in the TEE dirty room should be discarded. Standard IC.02.02.01 The hospital implements infection prevention and control activities when doing the following (EPs Survey finding) EP 4 The hospital implements infection prevention and control activities when doing the following: storing medical equipment, devices, and supplies. It was unclear if equipment was clean or dirty in several locations; some items were covered with plastic bags or wrapped with a plastic bag (required to identify clean items according to staff) and some items were not. In MIC surgical room and anteroom: It was unclear if equipment stored with sterile supplies was clean. A fluid warmer in the surgical room was not identified as clean. Sutures were stored in an open holder with no protection from contamination. 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings – Two laryngoscope handles with blades attached were sitting directly on the anesthesia cart out of packaging with a towel on top of them. In Imaging, the ultrasound probes are stored in a cabinet in such a manner that the scopes touch the shelf. Staff members do not routinely clean the inside of the cabinet. Recommend – The infection prevention specialist should review this. The flexible laryngoscope on the difficult airway cart is stored in a plastic tube that was cracked and dirty. It was not marked with the date of last reprocessing. Recommendation – Some organizations have moved to processing in Central Sterile with sterile packaging and others have moved to single use, disposable scopes. An uncovered laryngoscope blade and an opened but undated bag of electrodes were found during inspection of anesthesia carts in the OR. Scopes stored in Endoscopy are not freely hanging. Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard MM.03.01.01 The organization safely stores medications. Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing errors. Law and regulation and manufacturer guidelines further define the hospital’s approach to medication storage. (MM.03.01.01 EP 7, EP 8 finding in 2015) EP 3 The hospital stores all medications and biologicals including controlled (scheduled) medications in a locked, secured area to prevent diversion, in accordance with law and regulation. This element of performance is also applicable to sample medications. Note: Scheduled medications include those listed in Schedules II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1970. The code cart in the Wound Care Unit is not placed in a secured area when the unit is not operational. See – In multiple areas in the organization, large- volume IVs are stored in areas where nonlicensed staff have access. There was no evidence of training in HR files and the medication storage and access policy CL-370 does not address this situation. In the BH unit, one room is used for medication, code-cart storage, some supplies, and nutrition supplies. As a result of this storage situation, nonlicensed staff can access the room. On entering the room, a bag with three bottles of medication was unsecured in a bin awaiting pickup by the pharmacy. Follow-up needed – Some surveyors look for partially filled Propofol or other medications in syringes in the wide-mouth waste bins in the OR that could be removed. 6/24/17 Standard MM.04.01.01 Medication orders are clear and accurate. EP 15 Processes for the use of preprinted and electronic standing orders, order sets, and protocols for medication orders include the following: - Review and approval of standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership - Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines Currently an order for titration in the patient’s record has very little information and a simple note to titrate a medication and the concentration. Staff then refers to the lexicon built into the electronic record for specific requirements on administering. On review of a closed record for a patient that received a titrated medication, the details in the lexicon to provide a complete order are not part of the record. The record therefore did not contain a complete order. This may also be 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings - Regular review of such standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols - Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient’s care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. cited under HR.01.02.07 EP2 practicing within scope. Standard MM.05.01.01 A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital. EP 9 All medication orders are reviewed for the following: Other contraindications. A patient with chronic alcoholism and cirrhosis of the liver had Tylenol ordered for pain and Ibuprofen for breakthrough pain. As Tylenol is generally contraindicated for patients with liver disease, the staff gave the breakthrough medication instead. The contraindication was not identified on review by pharmacy. This may also be cited under PC.02.01.03 EP 1 for administering a medication outside of the MD order. 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard MS.03.01.01 The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process. EP 2 Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff. PAs and NPs do not have separately delineated privileges. It is the responsibility of the medical staff to determine their qualifications to exercise privileges, not the supervising physician (whose responsibility is the delegation agreement). 6/24/17 Mock Survey: Exec Sponsor for Level 1 Findings Standard EP Mock Survey Observation Summary Chapter Champion Exec Sponsor Corrective Action Due Date Report out to Reg Steering Date Standard PC.01.02.03 The hospital assesses and reassesses the patient and his or her condition according to defined time frames. EP 3 Each patient is reassessed as necessary based on his or her plan for care or changes in his or her conditions. A patient who was admitted to the ED for approximately 14 hours threatening suicide was discharged still stating he was suicidal. No further assessment for suicide was found on the record at time of review. 6/24/17 Standard PC.01.03.01 The hospital plans the patient’s care. (PC.01.03.01 EP 1 finding in 2015) EP 5 The written plan of care is based on the patient’s goals and the timeframes, settings, and services required to meet those goals. The goals reviewed were generally not measurable and timeframes were all set for discharge date. Some of the goals were pre-op goals or other goals that would have been complete well before discharge. The BH treatment goals were set for 7 days and reevaluated at that time even though some of the intervention had time goals of 2 days and the average LOS is 4 to 5 days. 6/24/17 Standard PC.02.01.03 The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation. EP 7 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital provides care, treatment, and services using the most recent patient order(s). A patient in the BH Unit with an active order for alcohol withdrawal protocol had been removed from the ordered assessments by staff. An active order for Toradol for 4 doses was noted; the last dose was not given and the IV removed. No order to address either discontinuing or restarting the IV. During the tracer on SSU, the patient had an order for Dilaudid for pain 8-10. The patient had a pain level of 5, but appeared to be in more pain and given that the patient was due to start physical therapy, the nurse gave the Dilaudid. It was not clear that a process for review or updating existing protocols was in place. 6/24/17

Paper For Above Instructions

The findings from the Mock Survey Executive Sponsor for Level 1 Findings reveal significant issues related to patient safety, risk management, and compliance with infection control standards within the healthcare organization. This assessment was conducted to evaluate the organization’s adherence to established healthcare regulations and guidelines, particularly focusing on standards set by the Joint Commission and OSHA, along with internal policies designed to protect patients and staff. A detailed analysis of these findings will provide insights and recommendations for corrective actions to ensure compliance and enhance patient safety.

Hazardous Materials and Waste Management

One of the primary findings centered around the management of hazardous materials and waste, specifically related to standard EC.02.02.01. The organization is required to ensure that all hazardous materials are appropriately labeled to identify contents and hazards, as set forth by OSHA and the National Fire Protection Association (NFPA) (Occupational Safety and Health Administration, 2023). The Mock Survey identified that several containers used for transporting soiled instruments in the Emergency Department (ED), Obstetrics (OB), and Intensive Care Unit (ICU) did not have the necessary biohazard labels. This oversight poses a risk not only to patients but also to staff and visitors who may inadvertently come into contact with hazardous materials. Immediate corrective actions should include retraining staff on the importance of proper labeling and the potential dangers associated with inadequate hazardous waste management.

Medical Equipment Maintenance

Standard EC.02.04.03 addresses the inspection, testing, and maintenance of medical equipment. The findings included that the hospital inadequately tracked the maintenance schedules and the testing of essential equipment such as dialysis machines (Joint Commission, 2023). For example, there was a lack of a "do not use after" date on chlorine testing strips, which are critical for ensuring safe water quality during hemodialysis. Such lapses highlight the need for a robust system to document equipment maintenance procedures, ensuring that staff are aware of and adhere to the timelines established by manufacturers to safeguard the wellbeing of patients receiving treatment.

Ventilation and Air Quality Control

Another critical area is the management of utility systems, particularly the ventilation systems designed to control airborne contaminants (Standard EC.02.05.01). Recommendations suggest that the organization should improve air management protocols to ensure proper pressure relationships and air exchanges in critical care areas, such as operating rooms (Facility Guidelines Institute, 2010). Ensuring the airflow and filtration system functions correctly is paramount, especially in environments exposed to airborne pathogens. This entails routine inspections and swift corrective action when any discrepancies are observed, such as doors that fail to close between clean and dirty areas.

Infection Prevention and Control

The Mock Survey revealed serious noncompliance with infection prevention protocols, particularly regarding the cleaning and sterilization of medical equipment (Standard IC.02.02.01). Staff reported inconsistency with the cleaning process for TEE scopes and other medical instruments used in the ED and ICU (American Hospital Association, 2023). This finding emphasizes the importance of regular training for all staff involved in cleaning processes and ensuring adherence to manufacturer instructions for use (IFU) in order to reduce infection rates associated with improperly cleaned instruments. Comprehensive training programs should be instituted to reinforce proper sterilization practices and documentation thereof, including the lot numbers and dates of processing chemical disinfectants.

Medication Management

The survey findings highlighted deficiencies in medication storage and security, particularly regarding controlled substances (Standard MM.03.01.01). The observation noted that medications were stored in unsecured areas, allowing nonlicensed staff access, which raises significant safety and regulatory concerns (Drug Enforcement Administration, 2023). Policies must be implemented to require all medication storage areas to be locked and to restrict access to trained personnel only. This might also involve conducting regular audits and security checks to ascertain compliance.

Care Planning and Patient Reassessment

Another area for improvement includes the assessment and reassessment of patients’ conditions per standard PC.01.02.03. The survey assessed scenarios where patients admitted with suicidal tendencies were discharged with insufficient follow-up assessments (National Institute of Mental Health, 2023). The implications are dire, as inadequate reassessment can lead to elevated risks for patients who are vulnerable post-discharge. Implementing more robust care plans that detail patient goals and settings tailored specifically to individual needs will enhance the overall safety and quality of care provided.

Recommendations for Corrective Action

Based on the findings, several recommendations for corrective actions emerge:

1. Implement comprehensive training programs for all staff focused on hazardous material labeling, equipment maintenance, and sterilization protocols.

2. Establish routine audits of infection control protocols to ensure compliance and efficacy, particularly in sterilization and disinfection processes.

3. Secure and restrict access to medication storage areas to licensed personnel only, alongside regular reviews of medication management policies.

4. Strengthen patient care planning and assessment processes to ensure all patients receive appropriate follow-ups and interventions based on their needs.

Conclusion

In conclusion, the Mock Survey identified critical areas where the organization must focus its efforts to enhance compliance with healthcare standards and improve patient safety. It is crucial that the organization prioritizes these recommendations to uphold its commitment to providing safe, high-quality care.

References

• Occupational Safety and Health Administration. (2023). Hazard Communication Standard.
• Joint Commission. (2023). EC.02.04.03 - Medical Equipment Management.
• Facility Guidelines Institute. (2010). Guidelines for Design and Construction of Health Care Facilities.
• American Hospital Association. (2023). Infection Prevention and Control Recommendations.
• Drug Enforcement Administration. (2023). Controlled Substances Act.
• National Institute of Mental Health. (2023). Suicide Prevention: A Comprehensive Approach.
• Centers for Disease Control and Prevention. (2023). Infection Control in Healthcare Personnel.
• World Health Organization. (2023). Safe Management of Wastes from Health Care Activities.
• Joint Commission International. (2023). Standards for Hospitals.
• The Joint Commission. (2023). National Patient Safety Goals.

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