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Discuss the current compliance status of the healthcare facility.
Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas:
Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All sprinklers must have at least 18 inches below and around of clearance for The Joint Commission standards. Review of department documentation shows that the master alarm panel for medical gasses was not tested annually per policy. This is a policy written by the hospital that is not being met. They are to follow the policies that they set for themselves. The Fire Drill History Report showed that the fire drill process is not adequate and does not meet standards. Quarterly fire drills are to be conducted as regulated by the Life Safety Code (TJC, 2013). Clutter was found in the hallways of 3E, 4E, OR and telemetry this could restrict people from leaving the floor safely in case of fire or smoke.
Accreditations function of Nursing Leadership it was discovered that Nurses on 3E were not documenting in a timely manner. When questioned they responded that they were “too busy”. Resulting in overtime and low morale on the unit causing discussion about staffing, staffing patterns and nurse to patient ratio. This is all established in a guideline for delivery of nursing care, treatment, and services (TJC, 3013).
Accreditation function of…...

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