Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 18: ANESTHESIA SERVICES 18.00.08 Equipment safety Overview of the requirement:
Tips for compliance:
n Schedule and document annual environmental risk assessment through review of all patient care areas. n Ensure risks identified include corresponding mitigation plans. One-on-one monitoring for patients identified as “at-risk” is an acceptable solution for areas that are not ligature resistant.
Anesthesia equipment is subject to regular preventive maintenance and individual medical records identify the machine used. Compliance is assessed through maintenance logs and medical record review. All deficiencies noted that some or all procedural patient records did not identify the anesthesia machine that had been used.
Comment on deficiencies:
Audit conditions in each department between risk assessments to ensure mitigation remains in place.
Frequency of citation:
22%
Examples of surveyor findings:
n Patient records lacked documentation of the anesthesia machine number.
CHAPTER 16: NURSING SERVICES 16.01.02 Pain assessment and reassessment Overview of the requirement:
n Add a required field for anesthesia machine number to surgical EMR records.
Tips for compliance:
CHAPTER 24: NUTRITIONAL SERVICES 24.01.03 Policy requirements: Food preparation and storage in patient care areas Overview of the requirement:
Patient pain is managed through assessment, intervention, and reassessment. Policies and procedures identify standardized tools (pain scales) and define the means and frequency of monitoring. This was a new standard as of March 2023. Compliance with this standard is assessed through observation, interview, and document review. Most findings noted a lack of reassessment, even when the hospital’s policy mandated a timeframe.
Comment on deficiencies:
Food storage and preparation in patient care areas is subject to written policies including defined elements. Compliance is assessed through observation and document review. Expired items, cleanliness, and temperature monitoring topped surveyor comments.
Frequency of citation:
28%
Comment on deficiencies:
Examples of surveyor findings:
n The policy “Pain Management,” lacked defined timeframes for pain reassessment after oral, intravenous, or intramuscular medication administration. n Three of nine records lacked a pain reassessment after the administration of pain medication as required by the facility’s policy, “Quality and Patient Safety: Pain Assessment and Management.” n The organization’s policy, “Pain,” instructs nurses to use the critical care pain observation tool (CPOT) to evaluate pain in nonverbal patients. In interviews with two med-surg unit RNs, they could not speak to methods used to evaluate pain in nonverbal patients. n Review policies for inclusion of all required elements. n Train staff to use the appropriate pain scales at the defined frequency. n Conduct chart audits to assess for compliance.
Frequency of citation:
22%
Examples of surveyor findings:
n Nutritional refrigerators were observed to be dirty with spills and food debris in the transitional care unit, cardiac medical unit, and cardiovascular intensive care unit. n Temperature logs for refrigerators and freezers located on nursing units were not checked daily as required by the standard. n Four milk cartons were observed in a patient refrigerator with a past “sell by” date. Patient assigned food was in the refrigerator two days after the patient had been discharged. Nutrition centers on all inpatient clinical units were observed to have food debris, dust, crumbs, and hair in the drawers and cabinets where patient food and food supplies are stored. n Minor cooking is done in the rehabilitation unit to allow patients to practice activities of daily living (ADL) skills. Supplies are currently procured by unit personnel from the local grocery store, not from the nutrition department. There is no collaboration relative to ADL cooking between the rehabilitation unit and food services as required by the standard. n Based on observation, the facility lacks a consistent process that demonstrates labeling of food product expiration/discard dates. n The employee food refrigerator was being used to store patient medications, such as insulin, that may be brought from home by patients to the sleep lab.
Tips for compliance:
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