Interview:

Surveyor covered all department representatives making sure care was multi-disciplinary.

Questioned age limit of pediatric patient and especially inquisitive about what was done to ensure safety of child when admitted to floor. Do we designate certain rooms for ped patients? Asked RT what special procedures do they follow when treating pediatric patients vs. geriatric patients.

What is the organization’s definition of an adverse drug reaction? Have you ever seen a definite here? How do you report? Discussed rate (0.7%) of drug reaction here which he says is below the national average. Asked if we may be under reporting.

Questioned pastoral care. Does chaplain use an assessment sheet? Spiritual assessment should be formal. Do we assess?

Tour:

• Checked bottom of linen cart
• Checked rooms thoroughly
• Checked temp in refrigerator

Medical Record Review:

• Condition of patient not checked on assessment – questioned this
• Checked for advance directive/living will – asked staff to show how you would know if patient had
• OP note dictated on 2/13 but transcribed on 2/14 – if it takes > 2 hrs. written note must be on chart.

Interview:

Asked if we had experienced any sentinel events and what we know about it.

Questioned doorway so close to visitor elevator and infant abduction, wanted to know what we had done to prepare if this happened.

Questioned our infection control rates. What were the percentages?

What outcome has been improved in this area because of PI?

Tour:

• Checked expiration dates on bottles
• Checked fire extinguisher

Interview:

Asked how they handle a situation where there are too few beds for patients since there is no Medical Director.

What is the difference in how you manage chronic and acute pain? Does the hospital provide any education for you to know how to do this? Do you use a pain scale?

Tour:

• Checked dates on drugs
• Questioned wasting of meds
• Questioned conscious sedation education

• Asked staff, do you have any extra certifications? Does the hospital encourage this?
• When was your last evaluation? Does the hospital require any min. amount of continuing education?

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Last Edit Of This Site:  04/10/00 07:51 PM
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