Volume 2024 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 12: PHARMACEUTICAL SERVICES 12.00.03 Drug and Biological Orders Overview of the requirement:
Drug preparation and administration meets accepted standards of practice and established policies. Drugs and biologicals are ordered by and administered under the supervision of qualified professionals. Compliance is evaluated through direct observation and document review. Most deficiencies noted pain medications prescribed without a pain scale to guide ordering/administration of these medications or practice that was in direct con- flict with written policy.
Comment on deficiencies:
Frequency of citation:
23%
Examples of surveyor findings:
n Three prescription pads were found in an unsecured cabinet with prefilled sheets for Zofran including the physician’s signature. These were given to every patient by the pre-op nurse for home use. there was no corresponding order noted in the medical record. n The organization uses two sets of standing orders that require nurses to make judgments about the severity of patients’ pain levels. Neither the order sets nor nursing policies delineate thresholds for pain. n Medical records contained orders for fentanyl, dilaudid, and oxycodone for “PRN pain” with no defined thresholds to guide prescribing. n Pre-op orders lacked required authentication. n One organization policy provides guidelines for range dosing. The policy, “Physician Order’s” states “Range orders are not allowed at the surgery center.” n A sample drug was present and through interview it was confirmed that it was being given to select patients and documented in the medical record. The “Sample Drug” policy states “No sample drugs will be utilized.” n Ensure that policies are not in conflict with each other. n Do not write medication orders prior to their intended use. n Train staff regarding requirements for authentication of orders.. n Establish pain scales to ensure consistent and appropriate dosing.
CHAPTER 15: PHYSICAL ENVIRONMENT 15.01.02 Temperature, Humidity and Air-flow Requirements Overview of the requirement:
Ranges for OR temperature, humidity, and air exchange rates comply with American Society for Heating, Refrigerating, and Air Conditioning (ASHRAE) requirements. Compliance is evaluated through document review and direct observation. Deficiencies were cited for failure to track temperature, humidity, and especially, airflow or for these to be outside of policy range with no corrective action taken to establish a more controllable environment.
Comment on deficiencies:
Tips for compliance:
Frequency of citation:
28%
Examples of surveyor findings:
n Air pressure relationships are not being monitored in the ORs. n Daily temperature, humidity, and airflow logs showed inconsistent documentation of airflow. n During surgery, the humidity in OR2 was observed to be 72%.
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