Volume 2024 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
Examples of surveyor findings:
n The policy on pain management did not address the frequency of initial pain assessment or reassessment. n Hospital policy requires pain reassessment within one hour following pain medication administration. Delinquent records had pain numerical scores documented between two and three hours after pain medication administration. n Nursing Administration policy for pain assessment does not specify timing of pain reassessment after administration of pain medication. n Pain management policies must include the use of a standardized pain assessment tool which may vary by department (based on patient need, e.g. pediatric vs. adult use), and frequency of initial and reassessment after administration of pain medication. n Policies can be shared by multiple services, as long as they are reviewed and readopted by each department as required.
Examples of surveyor findings:
n The hot and cold pass-throughs require daily temperature monitoring. Each was missing documentation for 12 days over the past two months. n Expired products were found in the department’s dry storage area. n Opened products were observed without expiration dates marked. n Dishwashing water temperature was not monitored twice daily as required by policy. n Accumulated dust and dirt was found on the top of the convection oven. n A build-up of grease was observed on the exhaust hood and fire suppression pipes with the potential to drip into food being prepared. n Frequent out-of-range temperatures were noted on the walk-in cooler logs and dish machine logs. n Unit-based patient nourishment rooms noted frequent out-of-range temperatures on the refrigerator logs. n More than 25 bins of single-serve items and condiments had no indication of an expiration date. Based on interview with the dietitian and nutrition services clerk, when the supply in a bin gets low, they place new supply on the bottom of the bin and the older supply on the top and do not worry about the expiration date because they go through their items pretty quickly. This process does not permit the hospital to monitor and remove supplies prior to expiration as required by the standard. n Provide an expiration date for all stored food items. Audit supplies regularly and discard expired products.
Tips for complianc e:
06.10 | Patient Rights 06.10.02 Notice and promotion of patient rights
Overview of the requirement:
A patient rights document exists and is provided to inpatients. Patient rights are conspicuously posted in the emergency department. Compliance is assessed through direct observation and document review. Surveyors noted variation in the rights based on presentation format that excluded some mandated content.
Comment on deficiencies:
Tips for complianc e:
Frequency of citation:
38%
Educate staff beyond documenting temperatures to act on temperature management. Train on actions to take if temperatures fall outside of the acceptable range.
Examples of surveyor findings:
n Patient rights are not posted at the ambulance entrance to the emergency department. n The rights listed in the policy, poster, and patient handout are different. n The rights are not posted in Spanish as required by the hospital’s policy. n Some required rights are omitted from the handout given to patients. n The rights included in the standard are mandated by CMS, so it is not a menu from which organizations can pick and choose. n Ensure consistency across all media that list patient rights (policy, handouts, posters, website).
n Ensure that kitchen areas are included in overall environmental rounding activities with a focus on maintenance and cleanliness.
Tips for complianc e:
06.08 | Nursing Services 06.08.12 Pain Management
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. Compliance is assessed through review of policy and inpatient medical records. Most deficiencies noted policies that omitted the timing of pain assessment, or action that deviated from policy.
Policies that go above and beyond to meet the needs of the CAH’s patient population, by requiring bi- or multi-lingual documents, for example, must be implemented consistently.
Comment on deficiencies:
Frequency of citation:
31%
achc.org | (855) 937-2242 | 31
30
Made with FlippingBook - PDF hosting