Email Discussion Group:Cited by JCAHO

H&P incomplete Yes. Our hospital (lab) was cited for incomplete admission History and Physical. This was not specific to the lab, but an overall hospital problem. H&P too brief We were cited because our physicians used the very brief review of systems contained in the consult note as their H&P. At a mock survey, we were cited for having flammable hairspray in lockers. ASA classification & airway The ASA classification and Airway had to be defined by the physician and the form signed prior to local being given. The JCAHO doctor and nurse were adamant about it. Called up verbal H&P We were also cited for not having an H and P on the chart prior to the procedure. Having a good relationship with the ED, we’ll get our acutes straight to the cath lab for direct stenting. Unfortunately for us, we had an acute come up while the JCAHO doctor was in the lab. The resident had called up a verbal H and P to us and said he was dictating one right at that minute. The inspector said that wasn’t good enough. The H and P must be written, signed and on the chart covering all systems prior to any intervention. No citations in CCL No. Our last JCAHO (for the CCL) was outstanding, though our hospital as a whole didn’t do quite as well. Site Verification Our hospital completed the JCAHO survey 3/17/03. The main question the surveyor asked of the cath lab was if we did side/site verification and time out. Despite a lengthy discussion, we received a recommendation for not having a policy related to site verification and time-out. The surveyor, who was very knowledgeable about cath lab procedures, stated that there are rare cases in which side/site could be life threatening, and he gave examples. He suggested that if there are no contraindications to sites then the one initially designated should be marked and it is stated during time-out that there are no contraindications to other sites. The Surveyor stressed that the JCAHO National Safety Goals relates not only to surgical procedures but all procedures. Too close to ceiling We were cited for shelving units too close to the ceiling. We did not have anything on the top shelf to comply with the 18 rule but they said because the shelves were taller, they would prevent the sprinkler system from fully covering all areas of the supply room. Our solution was to get a cutting torch on them and cut them down to 18 from the ceiling. Signing before procedure Yes, we were cited for not having ASA classification signed by the doctor before the procedure. We solved the problem by having a form prepared for signature by the physician. He is supposed to sign it before the procedure, but in the real world he signs it post procedure when he is writing his orders. No citations, but 2 interested questions Our cath lab was not cited when JCAHO came through about 2 years ago. However, they did ask questions regarding the crash cart (whether it was checked on the weekends when the cath lab call team came in) and also they were very interested in if a RN was in the room during cath cases at all times. Discharge criteria Yes, in a recent JCAHO Survey, our cath lab was cited due to not having medical staff-approved discharge criteria. We get our outpatients ready and keep them post procedure through discharge. Because of this, JCAHO requires that the medical staff approve the criteria upon which these patients are discharged and they had to be in policy. Our solution was to add the discharge criteria to our holding area policy. We also made an official discharge sheet, on which the RN only has to check off whether the patient meets each of the criterion. Both the policy and the form were sent to the Dept of Anesthesia, Dept. of Medicine and the Medical Staff Executive Committee for approval. The approval date was then placed on the policy and on the form. A list to watch No citations, but last time JCAHO was here (Dec ‘01), they looked at: Defib checks; Narcotics control(waste/count procedures and documentation and how long it is kept and where); Radiation monitoring and annual lead apron checks (documentation and its confidentiality also); Staff educational records and proof of licensure; Initial and ongoing competency checks (documentation in HR files); Conscious sedation policy, training; Ongoing competency checks consistent across departmental lines. Narcotic count We have not been officially cited, but the Joint Commission surveyor did not like the way we justified our narcotic count. Basically, what we did was justify with the pharmacy when we restocked every 2-3 days. The surveyor wanted us to do it on a daily basis, so we developed a form that is taken to pharmacy daily. That is a big pain, so we are in the process of installing the Pyxis system for narcotics only. Not cited but hit hard We have not been cited but there were several areas they hit pretty hard for us last year. These included: Security and expiration of medications; Expiration dates on all supplies like catheters, wires, sheaths, etc...; Improvement projects in which we could show collaboration with our physicians; Safety issues (fire, hazardous materials, etc...). Log checks A few years ago the in which I worked was cited when they reviewed a chart and saw that a patient had been cathed. It was a Saturday and JCAHO checked to see if we had done the daily test on the defibrillator. WE HADN’T! We did keep a log and everyone knew that if we came in to do a case after hours we were to check the defibrillator. Maybe it WAS checked, but it was not logged. It is important that everyone take ownership to this very important task. The manager can address those delinquent by checking the call schedule and time cards to see who worked. Checking, documenting, crossing your Ts We were asked by JCAHO if the cath lab fluoro is checked daily. We answered yes, of course, but we did not document it accordingly. We got a ding for that. Checking the fluoro every morning and documenting the results is usually done by the RTs. Now we track all repairs and diagnostics done by the fluoro and hemodynamic system service team. Moderate sedation is also a biggie! Be sure that your Is are dotted and Ts crossed. Nursing and doctor assessments especially! Even if they were done away from the cath lab. Good luck! Fluoro permit I am the Radiology Special Procedures Technician for a cardiac cath lab in California. Upon inspection, JCAHO learned that I did not have a fluoro permit. Our lab was fined quite a large penalty and I had to go to a 12-week school and take a state test in order to obtain my license. It’s a dilemma, because I am the only staff member with the fluoro permit who should scrub assist the MD during cases and the remaining staff are nurses without a permit. Why didn't the state insist that only staff with fluoro permits may scrub in case studies? Presently, nurses are not allowed to get a permit, only techs.

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