JC came to survey us last week. Here are the infection-control related findings we had:
- Limited air pressure gradient problems.
- We had an OR that was a little too cold.
- Water management plan was not reviewed annually, and did not include evaluation of the patient populations served to identify patients who are immunocompromised.
- Ice machine had hard water deposits on discharge chutes.
- Chair in ER triage area had tear in upholstery.
- HLD Trophon, one employee was not documenting quality control check.
- L&D unit, a sterile-wrapped basin was dusty.
- Pill cutter had not been cleaned.
- Home health - pulse ox was used and not disinfected prior to going back in bag.
We did review all the COVID vaccination stuff for employees/volunteers/students/vendors/contractors/construction. Tracking/counting has been a challenge. Better software would fix this problem.... currently using the NHSN spreadsheet, which does not calculate things correctly. And then we have an alternate process for vendors, as well as construction/electrical/plumbing contractors.
All in all - the surveyor had good feedback about infection control. Grateful to be done - our survey was originally planned for last summer.
Connie
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Connie Jubitz BSN, RN, CIC
Mid Columbia Medical Center
The Dalles, Oregon 97058
(541)296-7398
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Original Message:
Sent: 02-03-2023 10:39
From: Nancy Mitchell
Subject: Joint Commission
Has anyone had a recent Joint Commission survey? If so can you share any hot areas you are aware of? We are due to be surveyed at the end of the year so I am trying to plan ahead. Specifically did they look at your COVID vaccinations and any accommodation data? Thanks!
Nancy Mitchell RN, CIC
Infection Prevention /Staff Health Coordinator
Santiam Hospital and Clinics
Email : nmitchell@santiamhospital.org
Office phone: 503-769-9249
Cell phone: 503-498-8887
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