At the recent UNIFY Conference, the Joint Commission shared their Top Scoring Clinical Findings observed while during survey. Many of these observations have been on previous years’ lists, indicating that organizations continue to struggle to mitigate these challenges. Many of these findings correlate with our consulting team’s observations during mock survey activities. Organizations should review these opportunities and their own practices for gaps, as these should be considered regulatory focus items. As the second part of a two-part series, we’ll briefly review these common findings and provide recommendations for mitigation activities:
Patient Assessment / Reassessment Not Aligned With Policy:
- Noncompliance with Assessment and Reassessment Policies: Required patient assessments or reassessments were not completed according to hospital or organizational policies. Examples include missing documentation for vital signs. Incomplete nursing or psychosocial evaluations, and failure to perform required checks (e.g., neurological, respiratory, or wound assessments) within specified timeframes.
- Incomplete or Missing Documentation: Blank or incomplete sections in critical assessment forms, such as intake assessments, psychosocial histories, and medication effectiveness evaluations. This includes missing documentation for pain assessments, vital signs, and other required elements, which were often confirmed by leadership or department heads.
- Failure to Follow Physician Orders or Protocols: Staff not adhering to specific physician orders or established protocols, particularly regarding medication titration, monitoring, and reassessment after interventions. This includes failing to document required scores (e.g., RASS, CPOT, CIWA). Not reassessing after medication administration or not following frequency requirements for monitoring.
- Mitigation Strategies:
- Leverage existing groups for oversight (Nursing Practice Committee, etc.)
- Establish hard stops for documentation.
- Establish workflows with required documentation guidelines.
- Streamline documentation.
- Automate the audit process and report out opportunities and trends.
Medical Staff Non-Compliance With Bylaws / Policy:
- Incomplete or Missing Required Elements in History and Physical (H&P) Documentation: H&Ps often lack mandated components such as review of systems, family/social history, cardiac and pulmonary assessments, medication lists, or physical exam details. These deficiencies are repeatedly cited as noncompliant with Medical Staff Bylaws and organizational policies.
- Noncompliance with Timeliness and Attestation Requirements: Discharge summaries, H&Ps, and other required documentation are not completed within the specified timeframes (e.g., 24 hours, 30 days, or annually). Additionally, there are frequent instances in which required co-signatures or attestations by attending physicians are missing or delayed, especially for documents prepared by residents or advanced practice providers.
- Failure to Adhere to Credentialing, Privileging, and Policy Standards: Lapses in following credentialing and privileging protocols, such as missing documentation of approved privileges, a lack of required committee approvals, or providers performing services outside their granted privileges. There are also instances where organizational policies (e.g., for committee participation, consultation completion, or OPP frequency) are not followed as stipulated in the bylaws.
- Mitigation Strategies:
- Create hard stops in documentation as reminders.
- Incorporate documentation completion as part of the OPPE process.
- Audit documentation and provide data to MEC for mitigation.
- Streamline documentation to support compliance.
- Establish credentialing/privileging audits and report through MEC.
- Set up process checks and maintain the integrity of the process.
Pre-Anesthesia Assessment Not Aligned with Standards or Policy:
- Lack of Required Pre-Sedation/Pre-Anesthesia Assessment Documentation: Absence of documented evidence that required pre-sedation or pre-anesthesia assessments were completed prior to procedures involving moderate or deep sedation. This includes missing documentation of airway assessments (such as Mallampati scores), ASA (American Society of Anesthesiologists) classifications, and other required physical exam elements. Assessments were either not performed, not documented, or completed after the procedure.
- Non-Compliance with Hospital Policies and Procedures: Providers did not follow established hospital or organizational policies regarding pre-procedure assessments. Examples include failure to document required assessment elements (e.g., airway, ASA, NPO status, Aldrete score), incomplete forms, or evaluations performed by unauthorized personnel.
- Timing and Completeness Issues in Documentation: Improper timing or incomplete nature of documentation. Assessments were documented after sedation, or the procedure had already occurred, or lacked time stamps to verify compliance. In some cases, only partial assessments were completed, with missing information on cardiovascular, pulmonary, or airway evaluations, or on prior anesthetic history.
- Mitigation Strategies:
- Create hard stops in documentation as reminders.
- Incorporate documentation completion as part of the OPPE process.
- Audit documentation and provide data to MEC for mitigation.
- Streamline documentation to support compliance.
- Follow pre-procedure checklists and hard stop if assessments are incomplete.
Medical Record Documentation Missing For Care Provided:
- Missing or Incomplete Documentation of Protocols and Orders: Clinical protocols referenced in orders, such as for ventilator weaning, Oxygen titration, Medication titration, and various treatment protocols, were not included, linked, or available in the patient’s medical record. This includes protocols for blood transfusion, dialysis, feeding, and medication administration.
- Inconsistent or Absent Clinical Documentation: Incomplete or missing documentation of key clinical information, such as medication administration, vital signs, allergy information, and progress notes. Examples include blank or incomplete medication administration forms, missing documentation of group therapy attendance, and absent or inconsistent allergy documentation.
- Policy Non-Compliance and Documentation Gaps: Non-compliance with hospital or organizational policies regarding documentation. This includes failure to document required assessments (e.g., pre-and post-treatment assessments, safety checks), failure to follow documentation requirements for sample medications, and missing documentation of patient response to consultations or treatments.
- Mitigation Strategies:
- Hard stop including protocols in the medical record.
- Streamline process.
- Audit for compliance.
- Set up an automated tracking system for documentation completion.
Psychiatric Plan of Care Not Aligned With Standards:
- Lack of Active Medical Problems and Interventions in Treatment Plans: Omission of active medical problems and corresponding interventions from patient treatment plans. For example, records lacked documentation of interventions for conditions such as diabetes, infections, falls, and other medical issues that were actively being treated. When patients were receiving medications or therapies for these conditions, the treatment plans did not reflect these interventions.
- Failure to Offer or Document Alternative Therapies When Groups Are Refused: Absence of documentation or evidence that alternative therapeutic activities were offered to patients who refused scheduled group therapies. When patients declined group participation, there was either no record of alternative options being provided or the alternatives were generic and not tailored to the patient’s needs.
- Non-Individualized or Incomplete Treatment Modalities: Treatment plans found to be non-individualized, with interventions that were generic, routine, or identical across patients regardless of diagnosis or presenting problems. Additionally, some plans lacked input from all relevant disciplines, such as social work or psychiatry, or failed to specify the frequency and focus of interventions. This resulted in treatment plans that did not fully address each patient’s unique clinical needs.
- Mitigation Strategies:
- Leverage existing groups for oversight.
- Streamline plan of care process. Create hard stops to create/modify care plans.
- Create plan of care templates with customizable interventions.
- Audit for compliance and report results.
- Streamline group participation documentation.
- Implement treatment modality documentation templates that structure required documentation but allow for individualization.
Suicide Safe Environment Risk Assessment:
- Unidentified or Unmitigated Ligature Risks: Physical features in patient environments that present ligature or self-harm risks but were not identified or addressed in the hospital’s environmental risk assessments. Examples include unsecured or non-tamper-resistant screws, exposed plumbing, gaps in handrails, padlocks, and furniture with anchor points.
- Inadequate Implementation or Documentation of Mitigation Strategies: Risks were recognized in assessments, appropriate mitigation strategies were either not implemented, not documented, or not followed. This includes items such as medical beds, plastic bags, and patient monitoring protocols, for which mitigation was either missing or inconsistently applied.
- Presence of Contraband or Unsafe Items in Patient Areas: Presence of items such as plastic bags, cords, hooks, and unsecured equipment (e.g., fire extinguishers, housekeeping carts) in patient-accessible areas, which are either prohibited by policy or require strict control but were found accessible during surveys.
- Mitigation Strategies:
- Implement a comprehensive ligature/self-harm risk assessment process.
- Ensure staff are trained on what to look for regarding risks.
- Use an interdisciplinary team and shift members occasionally to gain other perspectives.
- Use checklists for mitigation strategies.
- Conduct periodic environmental safety checks.
Patient Care Not Following Medical Orders:
- Orders Not Followed or Implemented as Written: Patient care orders, such as medication administration, ventilator settings, dietary supplements, and monitoring protocols, are not carried out as prescribed.
- Lack of Documentation or Evidence of Care: Missing or incomplete documentation regarding the execution of orders. Absent records of vital signs, daily weights, intake and output, neuro checks, and other ordered assessments or interventions. No evidence that required notifications to providers were made, or that patient refusals were documented.
- Unauthorized Changes or Omissions in Treatment: Changes to patient care (such as adjustments to ventilator settings, oxygen therapy, or dialysis parameters) were made without a corresponding provider order or protocol. Staff acting outside the scope of the written order; Verbal orders or protocol deviations not adequately documented or communicated.
- Mitigation Strategies:
- Conduct root cause analysis for identified gaps and address contributing factors.
- Streamline documentation.
- Use hard stops.
- Audit documentation.
- Train staff.
For questions or to learn more, contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
