(Solution) AFT2 KCMI Task 4

Current Compliance Status

The current compliance status of the healthcare facility reveals multiple areas of non-compliance with The Joint Commission standards across several key focus areas. In the Environment of Care, smoke wall penetrations were observed on both the 1st and 4th floors, which violates standard EC.02.03.01. Additionally, the master alarm panel for medical gases was not tested annually per policy, violating EC.02.05.09, and the lack of adequate Interim Life Safety Measures (ILSM) during three construction projects is a breach of LS.01.02.01. These deficiencies directly impact the safety and security of the physical environment and require immediate attention. In the Life Safety category, clutter in hallways was noted in multiple areas, including 3E, 4E, the Operating Room (OR), and the Telemetry unit, obstructing access to fire extinguishers and other safety equipment, which violates LS.03.01.20. Furthermore, the fire drill process does not meet the required frequency standards (EC.02.03.03). The gift shop lacks the required 18-inch clearance from sprinklers, violating LS.03.01.35. These issues pose a significant fire hazard and could endanger patients and staff in an emergency.

Nursing Leadership is also compromised, as nurses on 3E consistently fail to document promptly, leading to overtime and low morale. When questioned, the staff cited being “too busy,” which raises concerns about staffing patterns and nurse-to-patient ratios. This directly violates NR.02.02.01 and LD.03.06.01. In the Record of Care focus area, verbal orders were not authenticated within 48 hours across multiple units, including 3E, 4E, 5E, the Emergency Department (ED), Telemetry, and during Performance Improvement (PI) data reviews, violating RC.02.03.07. Information Management standards are also not being met, as prohibited abbreviations were found in progress notes, nursing notes, and physician orders in 3E, 4E, the Intensive Care Unit (ICU), and Telemetry, which violates IM.02.02.01. Similarly, the Medication Management category reveals that a nurse on 4E failed to follow the range order policy, and an ICU nurse could not explain how the range dose policy is executed, violating MM.04.01.01. Unlabeled propofol syringes were found in the OR and Cath Lab, breaching MM.05.01.09 and NPSG.03.04.01.

In the Provision of Care, Treatment, and Services area, there was a lack of day-of-procedure reassessments in the Cardiac Cath Lab, Endoscopy, and Surgery Pre-op, violating PC.01.02.03. The ED consistently missed pain assessments and reassessments, breaching PC.01.02.07, and in Endoscopy, the absence of a pre-sedation ASA and a documented anesthesia plan violated PC.03.01.03. Additionally, the Universal Protocol standards were not met, as a bronchoscopy lab lung biopsy site and a knee arthroscopy site were not marked, violating UP.01.02.01. The National Patient Safety Goals were also compromised, with unlabeled basins and pre-labeled syringes from an external supplier in the OR, violating NPSG.03.04.01. In the Medical Staff category, the Ongoing Professional Practice Evaluation (OPPE) process does not meet standards, violating MS.08.01.01.

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