Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 30: SURGICAL SERVICES 30.03.03 Post-procedure follow-up call Overview of the requirement:
CHAPTER 25: PHARMACY SERVICES/MEDICATION USE 25.01.03 Security of medications Overview of the requirement: Medication is secured to prevent unauthorized assess. Comment on deficiencies:
Outpatient surgical patients receive follow-up calls 24 to 72 hours after discharge. Compliance is assessed through interview and document review. When documentation was not present in individual patient records, Surveyors noted that policy often failed to identify which patients should receive calls. Data from calls was not advanced to the QAPI Program for analysis and trending.
The standard is evaluated through observation, interviews, and document review. Most deficiencies noted the presence and easy accessibility of frequently diverted drugs.
Comment on deficiencies:
Frequency of citation:
51%
Examples of surveyor findings:
n Unsecured medications (vials and filled syringes) were found in clear plastic medication boxes located on the top of the anesthesia machines. n Multiple partially filled syringes of propofol were found in open container disposal boxes in each cardiac catheterization lab. n Unlocked, unsecured, clear, plastic pharmacy medication bins were observed next to the pyxis machines in inpatient medical units’ medication rooms. These bins were used to return medications to the pharmacy. Loose medications were observed in each of the bins. Based on interview, EVS, materials management, and unlicensed nursing staff have badge access to the medication rooms, leaving opportunity for those staff to retrieve medication from the bins. The medications in the return bins had been in the bins for up to ten days, so it is unclear how pharmacy is monitoring medication delivery and administration practices on the inpatient units. n An anesthesia cart was located in an unlocked storage room accessible to patients, visitors, and unauthorized staff. The anesthesia cart held a small waste bin which contained partially filled vials medications. Hospital policy states “Unused and non-empty containers with no pyxis alert and partial vials should be discarded in the non-hazardous Rx waste container.” n A shared nourishment/medication room is used to store non-narcotic medications, syringes, and needles. Based on interview, a risk mitigation plan in place requires an RN to accompany all unauthorized staff when they access the room to obtain nourishments for the patients, however, no written mitigation plan was available, and leaders stated it was a verbal plan. n Review how access to medication storage is managed, especially when drugs are stored with other items that require broad access. n Add observation of medication carts, cabinets, and other storage and disposal boxes to environmental surveillance rounding. n Policies should delineate the proper disposal of medications by medication type and disposal container type. n Train staff and providers on proper disposal of unused drugs and conduct audits to promote accountability. n Minimize the risk of diversion of unused portions of drawn up medications.
Frequency of citation:
22%
Examples of surveyor findings:
n Hospital policy required post-operative calls within 96 hours which is not compliant with the standard. n Information obtained during post-procedure follow-up calls is not tracked and reported to the QAPI Program. n The hospital’s policy is to call all outpatient surgical patients, but patient records had no documentation that this was being completed. n The hospital’s policy did not define which patients were to receive follow-up calls, nor did it identify that this applied to all surgical outpatients. n Audit hospital policy to ensure that it defines criteria for who receives a follow- up call, the time frame for the call, the information to be collected, and the action(s) taken with the documented results.
Tips for compliance:
Follow-up phone calls promote continuity of care, minimize returns to the ED, and support patient satisfaction.
Tips for compliance:
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