By A.J. Plunkett
Check patient units to ensure breast milk and other patient foods are stored correctly, encourage staff to reach out to providers if medication orders are not clear, and check crash carts for expired or missing items.
Those are among some of the highest scored problems not associated with infection control or suicide prevention, according to findings by surveyors with The Joint Commission (TJC) in the 12 months ending August 31, said Maura Naddy, MSN, RNC-OB, CJCP, senior associate director with TJC’s Standards Interpretation Group Operations & Quality Assurance department.
Naddy provided a review of clinical scoring trends during the 2022 Executive Briefing, held September 13 virtually and in person for the first time since the start of the COVID-19 pandemic.
Standards under Infection Prevention and Control and National Patient Safety Goal 15 on reducing suicide risk were still three of the top four most cited clinical requirements. However, of other clinical deficiencies found by surveyors, 56.4% landed in the moderate-risk category on the SAFER Matrix, 11.2% in high risk, and 0.5% in immediate threat to life and safety, said Naddy.
Here’s a rundown of the top five, with examples of findings and the compliance strategies offered by Naddy.
MM.06.01.01, EP 3—Medication Verification
Almost 40% of the deficiencies cited under this Medication Management standard fell under the high-risk category of the SAFER Matrix.
“That is our top scored clinical item outside of infection control,” said Naddy.
Providers need to make sure they are following the most recent medication orders, that medications are being administered as ordered, and that medications are visually inspected first.
Is part of the pill missing? Is the medication in the syringe cloudy? Does anything look wrong? Those are questions that should be constantly asked, she said.
Most importantly, if there is any uncertainty about the order, talk it over with the provider or pharmacist, she said.
“Staff should not be afraid to reach out to the provider, to have that discussion, because in the end patient safety is the key thing,” said Naddy.
Compliance strategies: Do your own chart or order reviews. Look at these with your frontline staff. They are the ones administering the medications, so if issues arise, they are going to know the details. Look for trends.
“Make sure you’re hearing their voice,” she said. “If you notice an issue, [ask] ‘how can we change it to make it better?’ ”
PC.02.02.03, EP 11—Food & Nutrition Storage
About half of the deficiencies found under this Patient Care element of performance (EP) fell into the moderate-risk category, broken down generally into the areas of location, labeling, monitoring, and cleaning.
If the patient is on special nutrition, is there any specific manufacturer’s instructions on where or how the nutrition is stored?
Does your organization have a process for labeling the nutrition with the date, time, and patient’s name? Often problems are found with storing breast milk, she noted. TJC doesn’t state what needs to go on the label, but “you want to make sure the right food gets to the right patient,” said Naddy.
If there are questions, go back to the manufacturer’s instructions. If the instructions are silent on the problem, look at FDA guidelines. The CDC also offers guidance for hospitals on storage of breast milk.
It doesn’t matter what the nutrition is, however. “I know juice doesn’t seem like a big thing, but we need to make sure we’re following manufacturer’s instructions for use [regarding] how things should be stored,” Naddy said.
If an item needs to be stored at a specific temperature, does your organization have a process to monitor the temperature based on manufacturer recommendations or evidence-based guidelines?
There is no specific TJC requirement to keep temperature logs on refrigerators or freezers. “But how do you know what the temperature of your refrigerator is and know that you’re within compliance, within the range that those temperatures should be, if you’re not logging it?” Naddy asked.
And finally cleaning: Are food and storage locations susceptible to contamination? “We don’t want patient food in a dirty refrigerator,” Naddy says, but be careful what products you use to clean the fridge. Determine who should oversee storage area cleaning and what products should be used and train staff on the use of the cleaning products, again according to manufacturer instructions.
PC.02.01.11, EP 2—Resuscitation Equipment
While 69.1% of the deficiencies under this Patient Care standard were in the moderate-risk category, 21.2% were found in the high-risk category of the matrix.
It may seem like it’s the little things that get scored, said Naddy, but in an emergency those things may save a life.
Surveyors will be checking to see if crash carts are kept in a location that is easily accessible as well as if there is enough equipment on the unit and within the facility.
They will also be asking about the process for managing used carts. Some hospitals use an exchange system—once a crash cart is used, it’s switched out for another cart that has been replenished and checked.
Are there appropriate supplies available to staff during the emergency? For instance, if there’s an emergency involving a mother with a child and you use the crash cart to care for the mother, are there supplies available to care for the child?
Are pediatric pads available for the automated external defibrillators (AED)? Are the AEDs charged? When were they last checked?
What is the process for monitoring and verifying that resuscitation equipment is appropriate to use? Are expiration dates checked? How often? Who’s in charge of checking them each shift?
Consider holding drills with different scenarios to ensure that staff know where they need to navigate to get to an emergency cart and what equipment will be available. Coordinate with your facilities and pharmacy staff.
“Those real-life scenarios, while they’re somewhat planned, it still shows you what those gaps are and where staff can learn and grow from,” said Naddy.
RI.01.03.01, EP 1—Informed Consent
Just under half of the deficiencies under this Rights of the Individual EP fell in the moderate-risk category.
Patients’ rights laws and regulations on informed consent can vary from state to state, so verify which apply in your state.
Surveyors will be asking about those laws and regulations, as well as what requirements your organization has in place to obtain informed consent.
Are consents signed, dated, and timed? How can your organization demonstrate that the informed consent discussion took place with the provider?
Review the CMS Conditions of Participation for deemed organizations and use a multidisciplinary approach to review your process.
Start there and then make sure your policy reflects a process that your staff can execute.
“When you are creating a policy, set yourself up for success,” said Naddy. “Oftentimes we see areas where organizations get very, very specific within their policy, and then it’s very hard for staff at the organization to be successful. And those are the times … where we see noncompliance, because they got way too specific or prescriptive within the policy.”
“Pull in those frontline staff because they are the ones that are doing these consents with the help of the providers,” she said. “That’s where you find the gaps.”
PC.01.02.07, EP 7—Pain Reassessment
Under this Patient Care requirement, more than 70% of the problems identified were in the category of moderate risk to patient health and safety.
And often, citations came because a patient did not have a pain reassessment within the time frame set out by the organization’s policy.
“For pain reassessments, The Joint Commission does not define a time frame,” said Naddy. “This is ultimately determined by your organization.”
Look for evidence-based guidelines as you review your policy, but remember that time frames for assessment after oral versus intravenous (IV) pain medications can be problematic because IV meds can act faster, warned Naddy.
Surveyors will be asking about your organization’s process for reassessing a patient’s response to pain medication, whether pain goals have been established, and whether the patient is making progress toward that goal.
They will also be asking about whether any side effects from the medication have been monitored and the frequency of monitoring.
In addition, surveyors will be looking at the risk factors according to the manufacturer instructions and the patient’s condition, “because this can be different for everyone,” said Naddy.
Again, she said, “set your staff up for success. Go over the process with them, educate them on the process. Pull them into when you’re creating the process because they are the ones that are going to be doing the reassessment.”
A.J. Plunkett is editor of Inside Accreditation & Quality, an HCPro publication.