Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 08: MATERIALS MANAGEMENT 08.00.03 Safe storage of supplies Overview of the requirement:
Items are stored in a manner appropriate to their use and protected from damage or loss. Compliance is assessed through observation. Deficiencies noted missing solid surface barriers on low shelving and unregulated storage of medications and supplies.
Comment on deficiencies:
Frequency of citation:
35%
Examples of surveyor findings:
n Storage shelves in Materials Management did not have solid barriers on the lowest shelves and the shelves were not 6” above the ground. Fourteen of seventeen shelves located in the surgery storage area did not have solid barriers on the lowest shelves. n Items appear to have fallen from the shelves in the main store room. Tape rolls and 4X4s were observed under the shelves, directly on the floor. n In Same Day Surgery, syringes, needles, and supplies are stored in unlocked cabinets in a medication room without a door. The ED medication room containing IV solutions, needles, syringes, and other supplies in bins and unlocked cabinets had one unlocked door. n Three of three supply room doors that opened into hallways leading to patient rooms were unlocked and accessible to anyone within the hallway. n Add expectations for storage in various locations to the environmental rounding audit tool. n Ensure all shelving units have a minimum six-inch floor clearance for non- sterile supplies and food item s, eight-inch floor clearance for sterile supplies, and a solid surface for bottom shelves. Don’t let convenience overtake safety. Supplies, like medications, must be secured to ensure access is limited to authorized personnel. Open doors and unlocked cabinets create risk.
CHAPTER 10: MEDICAL RECORDS 10.01.16 Informed consent Overview of the requirement:
Medical staff policies identify the procedures and treatments that require informed consent and the process for obtaining it. Medical records document the patient’s informed consent including, at least, the required elements. Compliance is assessed primarily through document review. Most deficiencies noted the failure to use patient-centered language; simple to understand but adequate to communicate the exact procedure.
Tips for compliance:
Comment on deficiencies:
Frequency of citation:
33%
Examples of surveyor findings:
n Consent forms were not written using language easily understood by a person without medical training, for example, OB consents used abbreviations CLE and C/S for continuous lumbar epidural and cesarian section. n Consents intended to be “simple language” lacked specificity as to the procedure, using “foot surgery” for a toe amputation. n Consents for procedures requiring anesthesia did not include the type of anesthesia to be used.
n Train relevant staff on the results of risk assessments for the presence of corrugated cardboard.
Tips for compliance:
n Educate all relevant staff on the informed consent policy at regular intervals.
Review forms for their use of simple language understandable by the individual providing consent.
n Train all staff that confirming comprehension is the goal, and it is achieved through a consistent, defined process.
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