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Aft2 Task 1 Executive Summary

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Executive Summary

Nightingale Community Hospital (NCH) is currently preparing for its triennial Joint Commission survey which is expected in approximately 13 months. The Joint Commission primary focus areas for NCH are Information Management, Medication Management, Communication, and Infection Control. The primary focus area outlined in this summary is Communication. The Joint Commission has three standards in which NCH is evaluated. Currently, NCH is non-compliant with standards UP.01.01.01 and UP.01.02.01. They are: * UP.01.01.01 - Conduct a pre-procedure verification process. * UP.01.02.01 - Mark the procedure site. As stated in the policy "Site Identification and Verification (Universal Protocol)," the Preoperative / Preprocedure verification is a five step process. This process needs to be expanded to meet the minimum standard of care. The following corrective actions must be immediately implemented. The patient must be properly identified at the time of admission. The admissions staff will require the patient to provide proper identification while verbally verifying their name and date of birth. If the patient is unable to verify their identity, a family member or other legal representative must be able to identify the patient. Identification bands will be verified and placed on the patient as the patient is being admitted. Confirmation of the patient’s identity must be established and documented. Transferring responsibility for care of the patient to another caregiver must be documented. The receiving caregiver must verify the identity of the patient by matching the patient ID band with verbal confirmation by either the patient or the transferring caregiver. The documentation must include the time and date of the transfer, and must also be signed by both the transferring and receiving caregiver. The pre-procedure hand-off…...

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