Clinical Care

DNV’s August survey yielded findings

But even with a short turnaround we were able to remedy nonconformities from the previous visit.


Asante concluded the 2023 DNV survey in mid-August. While there were several findings, your commitment to provide safe and high-quality care shined through. Asante was able to close eight of the 10 nonconformities from the February survey.

Closing these nonconformities in an expedited timeframe (six months instead of one year) is a testament to the collaboration between departments and focus on patient safety.

Asante received a total of 13 nonconformities: five NC-1s and eight NC-2s.

NC-1 NC-2


MM.4, SR.1, Pain Assessment

Missing pain assessments prior to medication administration.

PE.2, SR.6, OR Fire Drills

Missing second- and third-shift fire drills.

ARRMC NS.3, SR.3, Pain Reassessment Post-intervention

Missing post intervention reassessment for pain medication administrations.

PE.5, SR.5, Medical Gas & HAZMAT

Missing signage on chemical waste, improper authorization and missing staff training for sharps manifests, and improper medical gas storage.

MM.4, SR.1, Duplicate Medications

Multiple medications for same indication without specific instructions for use.

IC.1, SR.3, SR.5, Infection Prevention & Control

No standardized process for cleaning oxygen regulator adaptors, dust in storage areas and vents, uncleaned refrigerators, expired products in refrigerators, staff refrigerators being used to store patient supplies, damaged and missing floor tiles, and corrugated cardboard boxes.

PR.5, SR.1, Informed Consent

Missing anesthesia type on consent forms.

PE.3, SR.1-4, Safety Management

Expired calibration on a thermometer, blocked access to fire-rated storage, improper transport of equipment, patient supplies stored in staff refrigerators, expired MRSA swabs and expired patient food.

PE.2, SR.10 Fire Life Safety Testing and Inspections

Loaded or lose sprinkler components, fire door inspection records, laundry chute door not closing and missing signage on compressed gas storage room.

PE.7, SR.6, Medical Equipment

Expired preventive maintenance on medical equipment.

ATRMC PE.8, SR.7, OR Humidity

Unmonitored humidity levels in surgical core and humidity levels exceeding maximum levels in OR suites.

SS.4, SR.7, Informed Consent

Missing anesthesia type on consent forms.

PR.7, SR.7. Violent Restraint and Seclusion Analysis

Missing analysis for violent restraint and seclusion data.

Many corrective actions are already underway or complete. Special recognition goes to the Facilities teams at each hospital, who have worked diligently to correct nearly all nonconformities in under a month.

Work continues to correct and close the informed consent nonconformity. This nonconformity has been open since 2022 and requires a review of the informed consent process and form. Southern Oregon Anesthesia has been actively participating in helping to resolve this nonconformity. The development of an anesthesia consent form is being explored as an option.

A multidisciplinary team was established to work through the pain assessment, reassessment and duplicate medication nonconformities. Epic teams are working on a sidebar activity report that will increase the ease of documentation and bring awareness to outstanding documentation elements, such as pain assessments and Pasero Opioid-Induced Sedation Scale (POSS).

Additional communication focusing on a comprehensive and team approach to pain and medication management will be coming soon.

There are things you can do to support this effort and provide good patient care. Make sure you are entering a functional pain assessment and POSS prior to administering a pain medication. Be sure to document whether the intervention was helpful under the post pain/comfort intervention reassessment flowsheet row and a reassessment of the POSS. Both reassessment items need to be completed within one hour of administration.

This survey puts Asante back on the normal yearly survey cadence. A special thank you to everyone who participated in the survey and interacted with the surveyors.

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.

Tags: Angela Kasprzak, DNV, findings, nonconformities, STAT
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