Volume 2025 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
Compliance tips for:
CHAPTER 16: RESTRAINTS 16.00.17 Monitoring of the patient Frequency of the citation: 44%
The standard’s intent is that each patient undergoing a surgical procedure is provided with information that is adequate (complete and understandable) to make an active choice about accepting or rejecting a proposed treatment. A patient who does not understand what they are agreeing to is not providing informed consent. ■ Audit consent forms for inclusion of all required elements and the use of simple language. ■ Audit surgical patient records for inclusion of documented consent. ■ Develop a defined, consistent process for obtaining consent that confirms patient comprehension. Train all relevant staff on the informed consent policy and procedure at regular intervals.
Nerd Newbies (understand the requirement)
Overview of the requirement: Appropriately trained staff must provide ongoing assessment and monitoring for patients under restraint or seclusion. Comment on deficiencies: Compliance is assessed through review of medical records. Findings focused on failure to meet policy requirements for monitoring time frames. Examples of ACHC Surveyor findings: ■ The facility’s “Restraint and Seclusion Policy” requires reassessment every two hours. One of two records reviewed lacked timely reassessment on nine incidents. ■ One of six restraint records listed the patient as having an order for violent bilateral wrist restraints. Patient monitoring was completed every two hours instead of every 15 minutes which was out of compliance with the hospital’s restraint policy. ■ One of five restraint records lacked evidence of every 15-minute patient monitoring for a patient who received a chemical restraint. Medication was given at 0115 and again with a new order at 0332, with no documentation of the checks between dosages or after the second dose as per hospital policy.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
08.03.06 Equipment safety Frequency of the citation: 56%
Overview of the requirement: Anesthesia machines undergo documented preventive maintenance per manufacturer’s recommendation and requirements of the FDA Safe Medical Device Act. Comment on deficiencies: Compliance with this standard is assessed through medical record review. Findings universally noted that the anesthesia machine used for the procedure was not identified. Examples of ACHC Surveyor findings: ■ Medical records lacked documentation of the anesthesia machine used and the “machine safety check" was not completed prior to use.
Compliance tips for:
The goal is to discontinue the use of restraint or seclusion at the earliest possible time. This standard defines expectations for monitoring (who, how, when) for a patient under this type of intervention. ■ Audit medical records to ensure restraint documentation compliance.
Nerd Newbies (understand the requirement)
Compliance tips for:
Nerd Apprentices (audit for excellence)
The intent of the standard is to create a traceable record of the equipment used in each episode of surgical care and to ensure that equipment is regularly inspected and maintained to work as expected. ■ Audit preventive maintenance logs for anesthesia machines and other surgical equipment. ■ Audit patient records to ensure documentation of equipment used. ■ Add equipment identification to a preprocedural checklist and add a check for the information to the post-procedural process.
Nerd Newbies (understand the requirement)
■ Train all relevant staff on monitoring restraint use and requirements for documentation of ongoing assessments. ■ Train others authorized to order restraints (physicians and other licensed practitioners) on the hospital restraint and seclusion policy.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 59
58
Made with FlippingBook - PDF hosting