Accreditation Audit AFT2 Task 1
Overview of Nightingale Community Hospital
Nightingale Community Hospital is an acute care non-profit hospital with 180 beds. They provide services in the following areas: General Medical/Surgical Services, Critical Care & Emergency Services, Oncology, Cardiolo...
Nightingale Community Hospital is an acute care non-profit hospital with 180
beds. They provide services in the following areas: General Medical/Surgical Services, Critical
Care & Emergency Services, Oncology, Cardiology, Telemetry Care, Vascular Lab,
Neuroscience Unit, Orthopedics, Imaging Services, Obstetrics, Level II Nursery, and Endoscopy
& Surgery. The central values of Nightingale Community Hospital are safety (with an emphasis
on patient-first customer care), community, teamwork, and accountability. In addition to their
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Accreditation Audit AFT2 Task 1
values, their mission is to create an environment of healing with passionate commitment to
excellence in healthcare. They strive to be the community’s number one choice for hospital care
and have a goal of providing treatment and prevention services in a cost-effective manner.
Nightingale Community Hospital receives Joint Commission Accreditation and therefore must
submit to audits from the Joint Commission. Two years ago when Nightingale Community
Hospital was audited, the audit found that several areas (specifically Infection Control,
Communication, Medication Management, and Information Management) needed improvement
in order to be fully compliant. In relation to the Communication portion of the Joint
Commission’s audit and subsequent findings and compliance status, a corrective plan of action to
ensure Joint Commission compliance will be outlined and include justification.
Compliance Status
Two years ago, The Joint Commission Survey Results found that Nightingale
Community Hospital was non-compliant in relation to Joint Commission Standard LD.04.01.05
which states, “The hospital effectively manages its programs, services, sites, or departments.”
The Joint Commission’s finding stated:
“It was evidenced through interview with three staff nurses that the leaders had not
effectively communicated to the nursing staff the policy related functional screening
criteria. Interview of three staff nurses revealed that they were not aware of the
functional screening process the hospital had implemented.”
Upon receiving these findings from The Joint Commission, Nightingale Community
Hospital conducted their own internal investigation to gain more detailed data relating to the
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