Specialties NICU


Well, they're coming this August. This will be my first JCAHO experience as a nurse.

My question is about those cute name signs that we post on the beds with the baby's first name on it. Are those JCAHO-approved? Or does it violate the no-visible-names rule? One could argue that it only has the first name on it so maybe it should be okay, but JCAHO's rules are pretty picky about names being visible. And what if it was actually the parents that put the sign up? Sometimes parents even make a sign that displays the baby's last name too.

I assume that in the interest of abiding by the rules we will just take all signs down temporarily, but I'm still wondering.

Jolie, BSN

6,375 Posts

Specializes in Maternal - Child Health.


I survived JCAHO as a new nurse manager 7 years ago. Despite all the ballyhoo, it was a very superficial survey, and we did fine. I think they tend to gloss over the highly specialized areas because so few of their surveyors are knowledgable about them. Find out what other hospitals in your area have been surveyed recently and contact the managers and staff there to ask what the " hot topics" were. JCAHO tends to pick one or two items each year, pain management and restraints, for example. Being a specialty unit, you'll have to show how you meet their criteria for these topics within your patient population.

Other than that, make sure your policies and procedures are up to date, your charting is up to snuff, your personnel and education records are current, and your unit is clean with all equipment in good repair.

The anticipation is far worse than the actual visit. Sadly, even if there were a major problem within a unit or a hospital, I seriously doubt that JCAHO would uncover it!

Jolie, BSN

6,375 Posts

Specializes in Maternal - Child Health.

Sorry, I rambled on and didn't answer your question about crib cards. I doubt that they will be a problem. I've never heard that raised as an issue.

I doubt it, because any place I've ever worked, the census board was out there for all to see.

prmenrs, RN

4,565 Posts

Specializes in NICU, Infection Control.

We were surveyed in November--that was not brought up as a possible issue. I don't think we did anything about that. It could be justified as helping w/"attachment" or some such garbage.

By the way, we just got an e-mail at work that we could have a "pop" survey any time after August. Guess when I'm retiring? August 1st!!!!! :D :roll ;)

NicuGal, MSN, RN

2,743 Posts

Specializes in NICU, PICU, PACU.

The crib cards were not a problem...but the charts and clipboards being out on the counters were! We have to put them in the cupboards or under the beds as these are confidential files!

Also...make sure the breastmilk is on the BOTTOM shelf of the fridge, not the top. And everything has to have a date and time when opened, no unlabeled flush syringes, undated and untimed formual, etc at the bedside. Make sure all drips are visibly labeled. If you set your feeds out early, make sure they are also labeled with name, date and time. If you keep meds at the bedside, we have a locked drawer that they have to be in (I know that not all hospitals do this, but that is one of our things since we don't have the med dispenser thingys). Countertops should be uncluttered...if the family has brought in a ton of stuff, we put it in the cupboards. Needle buckets should not be full or the tops jammed. Make sure you know where all the manuels are, the fire extinguisher and if you have evacuation aprons, where they are. Each bed that has a baby on a vent should have an O2 tank on it also.

Can you tell that I am always the one that gets to make the rounds with these people with the head nurse! :lol Those are the things that we have been called on. Charting is a whole nother experience! :imbar


62 Posts

When our unit did it two years ago they found a critical violation when they did pt chart reviews and then went looking for other things. Typically if they can't find BIG no no's then they just breeze through. Thats what they did last year when they returned and we did great. Apparently our charting did not demonstrate a nursing care plan to them, so they went looking for other issues. But we fixed that issue and our eval was fine last year. But crib cards were never an issue, pain management is a BIG one and they go back up to 6 months of charting so if you dont have a good pain assessment documentation system now get one. GOOD LUCK!!


1,334 Posts

Specializes in NICU.

Something funny happened last night... The hot water spigot on our coffee machine (of course located right next to the breast milk) was broken somehow and it was putting out a constant stream of hot water! At first it was very slow and we were able to absorb it with linens. But by the end of the night (after everyone used it to get hot water for warming bottles) it was a constant stream.

We ended up rigging up a little system where the water landed on our ice scoop on the counter then flowed off of that into a trash can on the floor. It looked awful funny to see this half-full trash can of water. I couldn't help but wonder what JCAHO would've said if they had done a surprise inspection!

babynurselsa, RN

1,129 Posts

Specializes in ER, NICU, NSY and some other stuff.

we had a AOA survey a few months back and we had to place all bed signs into clear plastic sheaths. You know like the ones you put into a notebook binder.

They did not want open papers hanging at the bed unless they were covered like this. I guess that was you could not soil or contaminate the paper and it was covered by something that could be wiped off.


427 Posts

We just had them come through. What a PITA. Do they really think that what goes on while they are there is what really goes on all the time? With regards to names, (non baby area, In ICU) first we couldn't have names on our wall boards, then we could, then we couldn't, finally we could, we couldn't list the MD or what service they were on as that would allow someone (ie visitors) to know what teh dx was, yeah right! awyho everything related to JACHO is a PITA, they are totally our of control. Did you now d5/1/2 ns with 20 meq kcl is a medication and must be locked up!!! We used to keep out blood drawing supplies ion he pt's room (only in critical care where everyone is pretty much stuck in bed) not anymore, all needles and angio caths are locked ion a seperate room, can't leave a chart out at the nurses desk!!! We passed, but jcaho seriously needs to be reeled in.

prmenrs, RN

4,565 Posts

Specializes in NICU, Infection Control.

I started a thread under "JCAHO" forum. Check it out, more of the same kind of nonsense.


95 Posts

Crib cards are fine as long as they are encased in plastic, just make sure the babies also have ID bands on. Good luck, it'll be here before you know it!!

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