QUALITY cum FACILITY ROUNDS FINDINGS –05/10/2024
Dept./Person
Department Observations & CAPA Taken Photo Evidence
Responsible
-Multiple Oxygen Cylinders parked. Only one cylinder found Nursing In-charge
BME
to have flow meter & checklist. No checklists available for
Housekeeping
other cylinders. Informed the floor in charge & ward ICN
assistant regarding use of checklist mandatorily to ensure
safety.
-Cylinder with oxygen flow meter found to have leakage
contributing to risk of fire hazard. Informed the floor in
charge & ward assistant regarding immediate escalation of
such issues to concerned department to ensure safety.
-Dump of stock found in an area marked dirty utility. It was
informed to Housekeeping team to clear the dump and
make facilities for utilizing the space as designed.
th
6 Floor -With respect to observations raised from assessors in
recent NABH Surveillance Assessment, it was informed that
the patient information display board to be updated only
with UHID, Consultant Name, DOA & Remarks. Patient
Name & clinical status was prohibited to be used on display
to ensure confidentiality of patient information.
-Discarding re-capped needles in white PPC is still found in
practice. Proper segregation of BMW to be done to ensure
compliance to statutory protocols.
-Medication Orders are not counter-signed by doctors as ICU In-charge
Director Critical
per the protocols. SNDT is not followed properly. Informed
Care
the concerned stakeholders to ensure compliance. BME
Civil
-Hand wash sink found not in use at Unit 2. Leakage issue
Hospital Safety
noted. Not repaired since many months. ABG Machine Officer
placed next to the sink area. To avoid splash of water on
the equipment, the sink was permanently closed.
It is mandatory requirement for a sink in the patient care
area. The equipment has to be moved to a safe space in
4th Floor ICU unit 3. The leakage has to be corrected immediately & the
Complex
sink has to be kept functional henceforth. In-charge to
ensure the action is taken.
-Stock of Bicarbonate Solution found stored in bulk near
patient lift on 4th floor ICU Exit door in front of ramp. The
storage & handling of hazardous materials are not as per
the standards, contributing to the risk of safety hazards.
QUALITY cum FACILITY ROUNDS FINDINGS –10/10/2024
Dept./Person
Department Observations & CAPA Taken Photo Evidence
Responsible
Terrace Kitchen: Kitchen In charge
Floor Dietary In charge
-Items stored in cold storage room, found to be stored for
more than 24 hrs. With an over written date labelling
-Hygiene not maintained in the entire unit. Cleaning was
done during the rounds.
-Use of gloves while handling of food not evidenced.
-Baking trays found to be unclean.
Chemo Ward:
Chemo In charge
-Patient safety parameters not met: Side rails not secured, Nurse
Nurse mentor
additional beds parked in the center of the unit.
-Staff unaware of safe practices related to disposal of
sharps as per protocols. On ground training given to ensure
compliance.
-Dirty Utility rooms are utilized for storage of Housekeeping Housekeeping In-
charge
stock. The hazardous materials found stored on floor. Lack
of proper storage conditions. The items to be re-arranged.
- Common spaces near lift are stocked with fresh puncture
proof containers on 5th floor & High cost cleaning
equipment on 6th floor. Items stocked to be cleared from
common areas & to be stored at a dedicated closed space
to avoid damage or pilferage.
5th & 6th
Floor
QUALITY cum FACILITY ROUNDS FINDINGS –23/10/2024
Dept./Person
Department Observations & CAPA Taken Photo Evidence
Responsible
Terrace Kitchen: Kitchen In charge
Floor Dietary In charge
-Items stored in cold storage room, found to be stored
for more than 24 hrs. Labelling for few items were
missing. Items to be discarded and only fresh items to
be used within 24 hours for cooking & discarded if left
over.
-Labelling of food items served to patients were found
with Bed No as form of identification. Instructed the
kitchen in charge to change the labelling methods and
use UHID No & patient names as identifiers instead of
bed number to avoid errors.
- Non Veg chopping area found to be dirty. Hygiene to
be maintained.
- Broken wash Basin in dish landing area. To be
repaired.
RO Plant: BME
-Periodic Cleaning & Maintenance checklist not
evidenced
Chemo In charge
Chemo Ward:
Nurse
-Water leakage from Refrigerator noticed. Defrosting Nurse mentor
data not maintained.
6th Floor Document Audit Findings: Housekeeping In-
charge
-Unauthorized abbreviations used
-Operation Theatre Notes missing from sampled file
(178005) for surgery happened on 19/10/2024.
-SNDT compliance not maintained in sampled files
(178221, 178045, 126456)
-Re-assessment on periodic intervals not evidenced in
doctors progress notes in sampled files (178005,
178221, 178045, 126456)
PATIENT & FAMILY INTERVIEWS
SL
PATIENT DETAILS OBSERVATIONS ON INTERVIEW CAPA Taken
NO
Subarna Ingfi (176239) - Side rails were not evidenced. - Secured immediately. Educated the patient & family on
1
- IV lines were not dated and timed. patient safety aspects.
- Consultant rounds not done on time Informed concerned stakeholders to ensure compliance
- Briefing from nurses on the available facilities & services & avoid deviation from protocols & processes
Syed Laga Abbas (178015) not done at the time of admission.
2
- Delayed shifting from A&E to ward (12:30 pm – 7:30 pm).
No Re-assessment done at A&E.
- Urine can to be provided.
- Patient ID band not found. - Informed assigned staff to immediately secure ID bands.
Renuka Hazarika (178102)
3 - Briefing about facilities available at ward not done by - Educated the patient & family on available facilities &
staff on admission. services.
- Patient ID band was missing. Side rails were kept down - Informed assigned staff to immediately secure the band.
Prabhat Chandra Kalita
for post op case. - Education given on the same to patient & family
4 (176733) - Facilities related to availability of Nursing call bell members
facilities were not instructed to the patient & family
members.
- Medical Administrative Officer sought advice from the
Gopinath Pegu (178221) - Issues related to constipation were not addressed by consultant on call for treating constipation & same was
5
caregivers. documented by the assigned nursing staff & on duty
RMO.
- Educated the patient & family on available facilities &
Mother & Child – - Congested Room.
services.
6 Sanjukta Deb (113345) & - Provision of glasses, spoon from kitchen department not
- Instructed kitchen staff on making provisions for the
B/o Sanjukta Deb (178696) available even after requests.
requests made by the customer.
