At the recent UNIFY Conference, the Joint Commission shared their Top Scoring Clinical Findings observed 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 own consulting team’s observations with mock survey activity. Organizations should review these opportunities and their own practices for gaps, as these should be considered regulatory focus items. As a 2-part series, we’ll briefly review these common findings and provide recommendations for mitigation activities.
Non-compliance with activities to reduce Hospital Acquired Infections (HAI):
- Organizations continue to struggle with complying with Manufacturer’s Instructions for Use (MIFU) and Infection Control Policies for cleaning, disinfecting, and maintaining medical equipment and instruments. Our team has observed significant debris on equipment items, including blood and body fluid, in some circumstances.
- Mitigation Strategies: Organizations should ensure staff have access to MIFU and know how to use it. Leaders must review cleaning and disinfection practices to ensure alignment with the MIFU.Observations of expired or improperly maintained supplies and equipment, including expired medical supplies, as well as improper labeling or lack of beyond-use dates on opened items, are consistently scoring as frequent observations. Additionally, equipment is not being maintained or cleaned as required.
- Mitigation Strategies: Reduce supply PAR levels; use just-in-time resupply processes to minimize the risk of expiring supplies. Centralize supply management as much as possible to leverage materials management efficiencies. Review biomedical equipment management practices to ensure all equipment is accounted for. Identify MIFU beyond use dates for supplies and post them for staff reference. Staff are observed failing to perform hand hygiene at required times, such as between glove changes or after removing gloves, and not using PPE as mandated by policy. There are frequent issues with staff having exposed hair, not using surgical caps appropriately, and wearing prohibited jewelry or artificial nails in clinical settings.
- Mitigation Strategies: Organizations should ensure accurate data for hand hygiene and glove use to validate identification of problem-prone areas. Leaders must set clear expectations for surgical/procedural attire and consistently enforce them. This would include modeling acceptable behavior and expectations. Additionally, establish a robust rounding practice on PPE wear and attire to validate acceptable practice.
Medications not administered per order or policy:
- Observations are being made where medications are not administered according to the specific provider orders. This includes administering a higher or lower dose than ordered, giving medication for a pain score outside the prescribed range, or not following titration protocols for infusions.
- Mitigation Strategies: Organizations should utilize established governing structures to address medication administration issues: Pharmacy and Therapeutics Committee, Medical Executive Committee, Nursing Practice Committee, etc. Ensure staff are trained on all medication administration policies, including requirements for a complete medication order, administering per order, and procedures to follow regarding questions/concerns with medication orders.
- Missing documentation or communication when deviations from orders occur is another frequent finding. Staff are not documenting patient requests for alternative pain management, failing to record reasons for withholding or altering medication, and not notifying providers when orders are not followed.
- Mitigation Strategies: Consider the use of range orders for titration medications unless prohibited by policy or state law to provide flexibility in administration. Determine the root causes of deviations from practice and address them. Ensure that patients are provided a variety of options for pain management that address all pain levels where applicable.
- Observations of mismatches between documented pain assessments and the medications administered. Patients are administered medications intended for different pain levels than those assessed (Giving medication for severe pain when moderate pain was reported).
- Mitigation Strategies: In addition to increasing staff understanding of medication administration policy, organizations should streamline documentation practices for ease of use and accurate reflection of care with pain assessment/medication administration. Review pain management practices: assessment and administration of ordered medication. Establish routine auditing of medication administration practices and address opportunities.
Resuscitation equipment and supplies not ready for use:
- Daily, weekly, or shift-based checks of crash carts, defibrillators, and emergency equipment are missing or not documented as required by organizational policy and/ or manufacturer instructions. This includes missing log entries, incomplete checklists, and discrepancies between paper logs and device records.
- Mitigation Strategies: Organizations should utilize current governing structures to address resuscitation resource readiness. Streamline equipment check documentation to make the process more efficient. Reduce repetitive documentation (such as initialing on every line of a crash cart check). Ensure leadership is rounding for compliance as part of their routine checks.
- Expired or Missing Emergency Supplies and Equipment: Expired items such as defibrillator pads, laryngoscope blades, Ambu bags, and other critical supplies are being found on crash carts or in emergency kits. Missing items, such as pediatric AED pads or oxygen tanks, and equipment are not being properly secured or locked.
- Mitigation Strategies: Streamline supply checks for expiration dates. Use barcoding to manage supplies. Pull expiring supplies from stock early to reduce risk. Standardize crash cart contents as applicable to support consistent management practices. Conduct leadership rounding for compliance and report results.
- Staff unable to demonstrate or verbalize correct procedures for equipment checks, or that checks were not performed according to policy or manufacturer’s instructions. This includes improper verification of defibrillator readiness, failure to follow protocols for securing carts, and a lack of alignment between policy requirements and actual practice.
- Mitigation Strategies: Review all resuscitation equipment MIFUs to determine routine functionality checks and post them on the crash carts for reference. Include equipment checks as initial and periodic competency evaluations.
High-Level Disinfection / Sterilization Not Aligned With Standards:
- During inspection of surgical instruments, there are consistent observations of damage, water spotting/rust on instruments, identification tape (peeling, not applied correctly), and inappropriate etching. Further investigation of practice indicates a lack of effective instrument inspection for damaged devices.
- Mitigation Strategies: Ensure that staff are trained and qualified with instrument inspection techniques and identification of unacceptable observations. Leaders should conduct spot checks of processed instruments to determine compliance with inspection practices.
- Staff are not following MIFU for high-level disinfection of equipment and supplies, including a lack of biomedical checks for sterilizers/endoscope washers, not performing and documenting control checks for test strips, and failing to clean equipment.
- Mitigation Strategies: Ensure staff are trained and qualified in high-level disinfection processes. Ensure MIFUs are available to staff and they know how to use them. Review MIFUs and assess for practice gaps with these requirements. Leaders should conduct spot checks and rounding for compliance.
- There are frequent opportunities for the storage of surgical instruments and devices. This includes failing to monitor temperature and humidity levels and not addressing excursions when they occur. Stacking fabric-wrapped instruments or peel packs in a manner that may damage the integrity of the packaging. Additionally, endoscope storage is not aligned with AAMI ST:91 2021 standards, including the use of non-HEPA filtered cabinets and the storage of scopes in procedural / disinfection areas.
- Mitigation Strategies: Ensure staff are trained and qualified in the proper storage of surgical instrumentation. Use centralized monitoring if possible to eliminate the need for clinical staff to monitor and document temperatures and humidity. Streamline excursion documentation to enhance efficiency and support compliance. Involve Infection Prevention in rounding for storage practices. Ensure alignment with AAMI standards for storage of instruments and endoscopes.
Food Items Not Stored Properly:
- Observations of food items-such as juices, sandwiches, meats, cheeses, and breast milk-being stored without required open dates, expiration dates, or patient identifiers. This includes both refrigerated and frozen products, as well as dry goods and spices. Observed noncompliance with organizational policies for labeling and dating of food items.
- Mitigation Strategies: Establish standard policy and practice for food storage and post them in food storage areas (such as nursing units). Have labels available in these areas for staff to use. Conduct routine rounding to remove expiring product.
- Missing or incomplete temperature logs for refrigerators and freezers, temperatures out of the required range, and a lack of documented corrective actions when variances occur. Seen across patient nourishment areas, kitchens, and specialty units, with policy-required monitoring not being followed or documented.
- Mitigation Strategies: Centralize temperature monitoring to ensure consistency in documentation. Use automation when possible to remove the human factor. Ensure the monitoring system is reliable and staff are aware of procedures.
- Observations frequently note expired food items, uncovered or improperly stored food, and unsanitary conditions such as soiled equipment, debris, or mold in storage areas. Examples include expired milk, cheese, and thickener packets, uncovered or partially covered food, and visible dirt or residue in refrigerators, freezers, and kitchen equipment.
- Mitigation Strategies: Establish routine cleaning of refrigerators and freezers. Routinely inspect food storage areas for cleanliness and sanitation. Centralize the responsibility of keeping food areas clean.
Informed Consent:
- Incomplete or Missing Documentation on Consent Forms: Missing elements such as date, time, witness signatures, or provider signatures on informed consent forms. Consent forms signed but not dated or timed; required witness or provider authentication was absent.
- Mitigation Strategies: Streamline consent form completion by removing redundancies and transitioning to electronic signatures that autofill date/time. Include consent form completion as part of pre-procedural checklists.
- Failure to Obtain or Appropriately Document Informed Consent: Informed consent was not obtained or documented as required by policy. Procedures performed without a signed consent, lack of evidence of consent for specific treatments (e.g, blood transfusions, psychotropic medications, dialysis), or use of verbal consent when written consent was mandated.
- Mitigation Strategies: Review organizational policy for consents and ensure that staff are trained on the procedures. Create hard stops with procedural checklists for consent completion. Streamline the consent process to ensure consistency and efficiency.
- Non-compliance with Policy Requirements for Consent Content: Consent forms missing required information, such as the specific procedure, risks, benefits, laterality, or the responsible practitioner’s name, unauthorized abbreviations, incomplete procedure descriptions, or missing documentation of the consent discussion.
- Mitigation Strategies: Review the consent process to identify gaps and drivers for non-compliance. Consider using customizable procedural consent templates for each patient, which provide core information on risks, benefits/alternatives. Include consent review as part of procedural checklists.
Reassessment and Response to Pain Not Aligned with Policy:
- Non-compliance with Pain Reassessment Policies: Pain reassessments not conducted or documented within the required timeframe after pain medication administration, as specified by hospital policies.
- Mitigation Strategies: Review current pain assessment/reassessment policy and practice to determine gaps and opportunities. Consider revising reassessment times to provide a greater time window for reassessment and documentation.
- Documentation Gaps: Missing or incomplete documentation of pain reassessment. Pain reassessment was not recorded, or the documentation lacked required details, such as pain scores or the timing of reassessment.
- Mitigation Strategies: Review current pain assessment/reassessment policy and practice to determine gaps and opportunities. Streamline and standardize pain assessment documentation. Use hard stops for documentation. Ensure there is a robust pain assessment/reassessment audit process with transparency of compliance data. Make pain assessment/reassessment an organizational priority.
Care Plans Not Specific to Patient Needs:
- Lack of Individualization in Care Plans: Care plans not tailored to the specific needs, diagnoses, or conditions of individual patients. Examples include care plans missing interventions for issues such as falls, pain management, diabetes, hypertension, or post-surgical needs, and the use of generic or identical goals across multiple patients rather than patient-specific plans.
- Mitigation Strategies: Leverage existing governance groups for oversight (Nursing Practice Committee, etc.) Streamline the care plan process to increase efficiency and compliance. Create care plan templates with customizable interventions.
- Failure to Update or Initiate Care Plans Based on Assessment/Reassessment: Care plans were either not initiated within required timeframes or not updated to reflect changes in patient condition, new diagnoses, or reassessment findings. This includes delays in initiating care plans, missing documentation for new or evolving patient needs, and care plans that fail to reflect changes such as new admissions, procedures, or complications.
- Mitigation Strategies: Streamline the care plan process to increase efficiency and compliance. Create hard stops to initiate/modify care plans, ensuring they remain up to date. Integrate care plan review with interdisciplinary team review.
- Incomplete or Missing Documentation of Required Consults and Assessments: Required nutritional, dietary, or specialty consults were not ordered or completed when triggered by patient assessments. Additionally, some care plans lacked documentation of essential assessments or failed to address all identified problems, such as nutritional risks, language barriers, or psychosocial needs.
- Mitigation Strategies: Automate consult initiation when triggered during assessments. Create hard stops to ensure consults are initiated. Create care plan templates with customizable interventions tailored to specific patient conditions.
For questions or to learn more, contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
