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TOP TEN DOH SURVEY CITATIONS RANDY BENSON Executive Director WHS Health Care Quality Service January 13, 2015.

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Presentation on theme: "TOP TEN DOH SURVEY CITATIONS RANDY BENSON Executive Director WHS Health Care Quality Service January 13, 2015."— Presentation transcript:

1 TOP TEN DOH SURVEY CITATIONS RANDY BENSON Executive Director WHS Health Care Quality Service January 13, 2015

2 TOP TEN DOH SURVEY CITATIONS The 2014 Top Ten “NO’s” From The Fire Marshal and Environment of Care Surveyors 10. Outdated Patient Supplies 9. Keys Left in Portable X-Ray Machines 8. Incompetent Employees

3 TOP TEN DOH SURVEY CITATIONS Top Ten “No’s” (cont.) 7. Penetrations of Fire Walls 6. Keyboard Skins 5. Unsecured Sharps, Syringes and IV Fluid Bags 4. Compressed Gas Cylinder Sprayers

4 TOP TEN DOH SURVEY CITATIONS Top Ten “No’s” (cont.) 3. Unsecured Confidential Paper In Cardboard Boxes Under Desks 2. Gaps at the Bottom of Hallway Fire Doors 1. EQUIPMENT PARKED IN A FIRE EVACUATION ROUTE HALLWAY

5 TOP TEN DOH SURVEY CITATIONS Outdates: Violate hospital policy, QI standards, CMS patient safety standards, lack of attention to details Keys: Unsafe practice (battering ram), violation of radiation safety standards Lacking documentation of competency, serious HR citation, all employees (not just nursing staff)

6 TOP TEN DOH SURVEY CITATIONS Fire Wall Penetrations: Violates hospital policy (Fire Marshal and EOC), lack of attention to detail Keyboard Skins: Infection control violation, patient safety issue (CMS standard) Unsecured Needles, Syringes and IV Fluids: Terrorism threat, theft, infection control, violates hospital policy

7 TOP TEN DOH SURVEY CITATIONS Confidential paper: Violation of CMS HIPPA standards, legal issue, competency issue Fire door gaps: smoke and fire barrier violation of Fire Marshal standards, patient safety, unsafe environment of care, lack of attention to detail Equipment in Hallway: Fire Marshal standards violation, failure to comply with clear standard

8 TOP TEN DOH SURVEY CITATIONS Other Issues: Fire Drills Dust on Window Sills: (All Things Related to Infection Prevention and Control) Mandatory Signage: (Patient Safety and Provision of Care) Disaster and Emergency Planning: The Soft Underbelly of Facility Operations (how responsive is the facility) Food Contamination in the Kitchen

9 TOP TEN DOH SURVEY CITATIONS QUESTIONS?

10 TOP TEN DOH SURVEY CITATIONS Randy Benson Executive Director WHS Health Care Quality Service (HQS)


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