Nightingale Community Hospital Case Study

A1. Compliance Status
“Nightingale Community Hospital (NGCH) has a vision to be the preferred hospital of choice for patients, employees, physicians, volunteers, and the community.” Their “mission is to create a healing environment, with a passionate commitment to healthcare excellence.” (Nightingale Community Hospital Brochure, n.d., p. 2) NGCH’s four core values are Safety, Community, Teamwork, and Accountability. Nightingale Community, as well as other hospital organizations, is governed by the Joint Commission. The Joint Commission is a non-for-profit regulatory organization that accredits and certifies U.S. based healthcare organizations.
Nightingale Community Hospital’s (NGCH) next Joint Commission survey is thirteen months away. Based
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Direct Impact:
• EC.02.03.01 – 1st and 4th floor have penetration issues with smoke rated walls
• MM.05.01.09 & NPSG.03.04.01 – OR has unlabeled propofol syringes
• NPSG.03.04.01 – Observed in OR; unlabeled basins and external supplier provided pre-labeled syringes in cataract packs
• UP.01.02.01 – Telemetry, ICU, 3E, and 4E is noted with the use of prohibited abbreviations in progress notes, nursing notes, and/or physician orders
• EC.02.03.03 – EOC does not have adequate fire drill processes or meet the standard frequency of fire drills
• EC.02.05.09 – EOC neglected to perform annual test of master alarm panel on medical gasses
• LD.03.06.01 & NR.02.02.01 – 3E nursing is not documenting in a timely manner resulting in low morale and
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The total average of compliance across the three departments is 87%. PACU is trending at the highest compliance of an annual 96.7%. The next highest compliance is in 3E with an annual 93.5%. The immediate focus for a Plan of Action will be to correct the annual 70.7% compliance in the ED. The pain reassessment audit in on a similar trending pattern compared to the assessment audit. The same three departments, ED, 3E and PACU, are compared in the audit with a collective annual average of 80.4%. Unfortunately, the annual average ratings are lower than in the assessment audit; PACU – 93.5%, 3E – 92.9%, ED – 54.8%. The ED will be added to the Plan of Action to correct compliance for pain reassessment.
Joint Commission PC.01.02.07 covers the assessment and management of the patient’s pain. Pain is to be assessed based on the patients care and treatment being provided. The assessment should also take into consideration the patient’s age, physical and mental condition. Caregivers and clinicians should follow Nightingales policies and procedures that detail out additional criteria as well as following standard medical practices in accordance with federal and regulatory governances. The reassessment of pain would follow the same guidelines. Based on the low percentages being recorded in the ED, Nightingale would be subjected to ensuring compliance for

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