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DNV notes findings in recent ARRMC survey

Auditors reported 11 nonconformities, but also praise for many hospital practices.



ARRMC completed its DNV accreditation survey mid-June. While several nonconformities were found, your dedication to provide quality care in a compassionate manner to our patients was evident.

The intent of these annual surveys is to recognize the efforts being done to improve patient care at all levels and to help identify areas of opportunity. DNV has three levels of nonconformity findings, shown in the accompanying column. ARRMC received findings in all nonconformity levels; including a serious safety condition-level finding.

Five NC-2 findings:

  • Internal audit and outdated policies.
  • Annual review of the effectiveness of the pain-management system.
  • Delivery of the Important Message from Medicare, or IMM.
  • Informed consent documentation.
  • Inadequate storage of medical gas cylinders and hazmat destruction documentation.

Five NC-1 findings:

  • Pain management and epidural documentation.
  • Pain assessment documentation.
  • Infection control risks, including: external cardboard shipping boxes in patient care areas, equipment and environmental cleaning processes, and uncleanable and damaged furniture.
  • Physical environment/life safety routine testing frequency, storage of spare sprinkler parts and fire door deficiencies.
  • Offsite generator remote stop and emergency generator spare parts.

One NC-Condition finding:

  • Ligature risks in PCU; immediate steps were taken to mitigate and prevent potential patient harm. Condition-level findings require an unannounced follow-up survey within 60 calendar days of when the nonconformity was identified.

The DNV surveyors were impressed by the dedication, enthusiasm and friendliness exhibited by our staff and leaders. Several noteworthy efforts include:

  • Engagement of the patient during the bedside handoff.
  • Staff engagement and resiliency efforts, such as: crisis care interventions, staff social worker support, Zen den, and staff recognition and bio boards.
  • Asante’s processes to minimize patient falls.
  • Sterile processing procedures.
  • OB-ED services provided to the community.
  • Nonviolent and violent restraint documentation.
  • Quality initiatives across various departments.
  • Continued focus on staff education.
  • Flexibility of staff to care for and manage boarders.

I am pleased to announce that your diligent efforts paid off; all nonconformities identified in 2020 were closed. DNV completed surveys at AACH and ATRMC in May. Thank you for all you do every day to keep our patients safe, and a special thank you to everyone who participated in the DNV survey.

Nonconformity key

NC-Level 2: There is an established process with an opportunity to ensure greater consistency.

NC-Level 1: There is no process or there is a significant variation in how the process is followed.

NC-Condition: There is a broken process with a patient-safety component.

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