Recommendations

We recommended that facility managers review privilege forms annually and document the review.

We recommended that facility managers ensure that privileges granted are appropriate for the practitioners’ skills and training.

We recommended that when conversions from observation bed status to acute admissions are 25–30 percent or more, the facility reassess observation criteria and utilization.

We recommended that the Acute Care Advisory Board review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.

We recommended that the facility keep the recipient list for the automated e-mail notification current

We recommended that the facility analyze electronic health record data at least quarterly and include most services in the review of electronic health record quality.

We recommended that the facility implement a process for the destruction of original documents.

We recommended that the Safe Patient Handling Committee report patient handling injury data quarterly.

We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.

We recommended that the facility designate Automated Data Processing Applications Coordinators to train employees and to manage, implement, and maintain the computerized consult package.

We recommended that the facility conduct cardiac arrest, contrast reaction, and fire emergency drills in magnetic resonance imaging and that facility managers monitor compliance.

We recommended that Level 2 magnetic resonance imaging personnel and/or radiologists document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.

We recommended that the facility ensure all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.

We recommended that facility employees regularly test the two-way communication device and that facility managers monitor compliance.

We recommended that the facility update local magnetic resonance imaging policies for policy changes and review the policies at least every 3 years and that facility managers monitor compliance.

We recommended that the facility revise the stroke policy to include clinical protocols or pathways, timeliness of completion and interpretation of computed tomography scans, emergent transfer to the nearest primary stroke center, the difference in approach to patients presenting within the facility’s defined timeframe for tissue plasminogen activator and those presenting outside of that timeframe, and screening for difficulty swallowing prior to oral intake and that facility managers fully implement the revised policy.

We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.

We recommended that facility managers post stroke guidelines in the Emergency Department and community living center and on all inpatient units.

We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.

We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.

We recommended that facility managers provide a stroke education program for employees who assess and treat stroke patients.

We recommended that domiciliary employees conduct and document monthly domiciliary self-inspections that include all required elements, submit work orders for items needing repair, and ensure correction of any identified deficiencies and that domiciliary managers monitor compliance.

We recommended that domiciliary employees perform and document contraband inspections, rounds of all public spaces, and inspections for unsecured medications and that domiciliary managers monitor compliance.

We recommend that the domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.

We recommended that facility managers ensure that closed circuit television with recording capabilities is installed in all domiciliary public areas.

We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.

We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.

We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.

We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.

We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.

We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.

We recommended that the facility ensure that all Emergency Department clinicians and clinicians with moderate sedation privileges have emergency airway management privileges.

We recommended that facility managers strengthen processes to minimize a repeat occurrence in which non-privileged providers perform intubations and in instances of occurrence, initiate root cause analyses.

We recommended that facility managers ensure quarterly reporting of emergency airway management data to the designated committee.

We recommended that facility managers ensure reporting of results of completed Focused Professional Practice Evaluations for all newly hired licensed independent practitioners to the Medical Executive Committee.

We recommended that facility managers ensure the Medical Records Committee monitors the copy and paste functions.

We recommended that facility managers ensure patient notification of positive colorectal cancer screening test results within the required timeframe and that clinicians document notification.

We recommended that facility managers ensure responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.

We recommended that facility managers ensure patient notification of diagnostic test results within the required timeframe and that clinicians document notification.