In 2023, the healthcare industry witnessed a considerable number of citations issued to hospitals across the United States. According to data from the Centers for Medicare & Medicaid Services (CMS), a total of 4,980 citations were delivered to hospitals during the year. Among these, the most common citations were related to providing “care in a safe setting.” In addition, the 15 most common hospital citations represented nearly one third of the total citations delivered.
CMS Grants Accreditors Deeming Authority
CMS has granted The Joint Commission (TJC) and DNV Healthcare (DNV) deeming authority for Critical Access Hospitals, Hospitals, and Psychiatric Hospitals. Center for Improving Healthcare Quality (CIHQ), and Accreditation Commission for Health Care (ACHC) have deeming authority for Hospitals. All of the accreditors have deeming authority over additional health care programs. For purposes of this blog, we are focused on the Acute Care and Psychiatric Hospitals.
When CMS grants an accrediting organization deeming authority, it means that CMS recognizes the accrediting organization as having standards and processes that are at least as rigorous as CMS’s own standards. This recognition allows the accrediting organization to conduct surveys of healthcare facilities on behalf of CMS.
Be aware, the accreditation process and standards align with the general principles covered by CMS requirements, however, the specific requirements and language used may differ. Healthcare organizations must adhere to both the accreditor and CMS standards to maintain compliance and ensure high-quality care for patients. It is essential for healthcare organizations to review the detailed standards and regulations provided by both the accreditor and CMS to meet their specific requirements.
Accreditation organizations conducted nearly 4,000 surveys, shedding light on the areas where hospitals needed to improve their practices. This data includes both Acute Care and Psychiatric Hospitals. In this blog post, we will explore the most common reasons hospitals received citations and the implications of these findings for patient care and safety.
15 Most Common Hospital Citations in 2023
1) Patient Rights: Care in a Safe Setting (255 citations 4.5%)
Findings: Failure to provide patients with care in an environment that meets safety standards. This could include issues related to physical safety, equipment maintenance, or emergency preparedness.
2) Patient Rights (213 citations; 3.9%)
Findings: Violations of patients’ rights, such as informed consent, privacy, or communication of their rights during their stay in the hospital.
3) RN Supervision of Nursing Care (201 citations 3.6%)
Findings: Inadequate supervision of nursing care, including issues related to nursing skill mix, or competence.
4) Nursing Services (131 citations 2.5%)
Findings: Related to nursing services such as insufficient staffing, inadequate training, or poor documentation practices.
5) Medical Screening Exam (120 citations 2.3%)
Findings: Deficiencies in conducting thorough and timely medical screening exams, especially in emergency department settings.
6) Compliance with 489.24 (Transfers) (113 citations; 2.1%)
Findings: Issues related to compliance with federal regulations governing patient transfers between healthcare facilities.
7) Patient Rights: Free from Abuse/Harassment (99 citations1.7%)
Findings: Issued when hospitals failed to protect patients from abuse or harassment, possibly involving staff or other patients.
8) Supervision of Contract Staff (87 citations 1.6%)
Findings: Stemmed from ineffectively supervising and monitoring contract staff, resulting in potential or actual suboptimal care delivery.
9) Nursing Care Plan (83 citations; 1.5%)
Findings: Deficiencies in developing and implementing nursing care plans tailored to individual patient needs.
10) Patient Safety (78 citations: 1.4%)
Findings: Patient safety risks related to medication errors, falls, infections, or other safety lapses that put patients at risk.
11) Administration of Drugs (74 citations; 1.4%)
Findings: Related to issues in the administration of medications, such as dosage errors or improper documentation.
12) Staffing and Delivery of Care (74 citations; 1.4%)
Findings: Inadequate staffing levels or issues with care delivery processes leading to potential or actual patient safety events.
13) Infection Control Program (69 citations; 1.3%)
Findings: Shortcomings in infection control practices and protocols, including issues with hand hygiene, isolation precautions, or sterilization processes.
14) Patient Rights: Restraint or Seclusion (65 citations; 1.2%)
Findings: Improper use of restraint or seclusion techniques on patients related to not meeting requirements for closely monitoring and safeguarding patients.
15) Quality Assurance/Performance Improvement (QAPI) (58 citations; 1.2%)
Findings: Deficiencies in quality assurance and performance improvement programs, indicating a need for more robust monitoring and improvement efforts.
These citations serve as a means of identifying areas where hospitals must make improvements to ensure patient safety, quality of care, and compliance with accreditation and regulatory standards. Addressing these findings is crucial for healthcare organizations to deliver a high standard of care to the individuals and population served.
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