Removing items from Regulatory Audit sheet

[samyer]

Please state what you would do in this scenario?

You are responsible for monthly regulatory compliance audits. There is an item on the sheet found to be out of compliance (refrigerator with vaccines stored in it that is in a non-secure location and left unlocked--this is in a hospital). You talk to the responsible employee and they argue stating "no one's ever had a problem with it before" and nothing is done. You mark the form indicating non-compliance, what your action was (talked to the employee) and submit to your supervisor. Next month, same thing found--frig unsecured. You again mark the form as 'out of compliance and hand in to supervisor drawing her attention to it. As you prepare to make rounds the next month you anticipate finding it again out of compliance and wonder what you should do.

What would you do?

• Do the audit and if out of compliance again mark it as such and say "oh well".
  
• Ask your supervisor if she would review the list and remove items that she wishes to not enforce (especially the one that has been out of compliance) with the explanation that it makes you uncomfortable having items repeatedly out of compliance on an audit sheet you are responsible for.
  
• Remove the item from the audit sheet yourself so you don't have to mark it non-compliant again
  

[Rose_Queen, BSN, MSN, RN]

How do you think you should proceed?

[samyer]

After I get some input I'll report what I did and the result of this actual situation. I did what I felt was right but the result was unexpected so I am interested in what other nurses think.

[Kooky Korky, BSN, RN]

I don't really know but I like the part about asking the Sup to remove the item from the audit form if nothing is to be done about it being out of compliance.

[samyer]

Kooky Korky, Thanks for your input.

What you picked is what I did. I wasn't comfortable with the other two options. I don't feel it is my place to remove items from an audit sheet (since I'm not the boss) and don't like being responsible for something and having it be documented as noncompliant, especially since these are audit sheets that surveyors may review.

So, I took the audit sheet to my supervisor (who is also responsible for the employee who argued with keeping the frig locked) and asked her to review it and remove items she prefers to not enforce (and thought I did it in a nonthreatening manner). Her response was to get angry--she never did tell me what she expected me to do or what she wanted done in the future so out of fear for my job I removed the item myself and haven't heard another peep about it. Feeling like I might have made a poor choice I wanted to see what others think.

Needless to say, I'm leaving this place of employment soon--pretty dysfunctional.

[Double-Helix, BSN, RN]

I would not have asked the supervisor to remove the audit item, nor would I have removed it myself. Medication refrigerators that aren't in locked rooms need to be locked. That's a regulatory requirement whether you have it on your audit sheet or not and removing it isn't going to help you if the JC comes to inspect your unit.

The question is whether you're responsible for that form beyond just doing the checks. If not, then it's on your supervisor to come up with an action plan. You're only job is to fill out the form and report the results. In my role, I'm responsible for establishing a plan for improvement/compliance and making sure it's being done. This would probably include education, ensuring that there is an available lock, doing 1-1 reeducation with non-compliant staff, and/or getting a code-protected refrigerator that locks automatically. But again, if your job is not to ensure that the unit is in compliance, I would continue to fill out the form, report the results, document on the form when and who you notified, and leave it at that.