CCC Survey Education Module Brandy Shannon, RN, MSN, DSD Clinical Educator March 2015

Purpose: Review the finding from the CCC Survey which provided educational opportunities and instruct the healthcare providers on methods of improvement.

Objectives: Staff will have a better understanding of the importance of compliance related to policies and procedures along with standards of Practice of the organization. Staff will be knowledgeable regarding the following topics: Sharps Containers Labeling Containers/Proper Labeling 3. Initialing Tube Feedings 4. Infection Control (Clean Med Carts, flushing toilets) 5. Narcotic waste

Sharps Containers Policy No: 8440.0300-Biohazard Waste Removal Plus Sharps All Sharps containers are to be checked on a daily basis by all staff as part of the everyday cleaning process and removed by EVS staff when 2/3 full.

Labeling Containers/Proper Labeling Standard of Practice: All specimen containers need to be properly labeled Unlabeled containers are not allowed in any area of the facility. All specimens must be labeled with Patient identification, date and time the specimen was obtained, and the initials of the person who obtained the specimen.

Infection Control Standard of Practice (Flushing Toilet): Flush Toilets after each use and upon emptying waste basin, specimen cups and graduated cylinders.

Infection Control Standard of Practice (Keeping Med Cart Clean): Nursing staff is make sure all med carts are kept clean and free from medication spillage. Nursing staff must check their cart every shift and clean cart as necessary.

Narcotic Waste Proper Wasting of Controlled Substances: Whenever a portion of a dose of controlled substance is unused, the portion MUST be destroyed by a licensed person in the presence of a 2nd licensed person who will serve as a witness. IF a full narcotic dosage unit is wasted, the charge nurse on duty MUST serve as a witness. ALL wastage will be recorded through the OMNICELL. Empty controlled substance vials/carpujects are disposed of in the BLUE pharmaceutical waste containers.

Narcotic Waste WHERE TO WASTE CONTROLLED SUBSTANCES WASTE DRUG - dispose by squirted into the pharmaceutical waste bin. EMPTY VIALS – dispose in pharmaceutical waste bin SYRINGES – dispose in sharps containers Controlled substance is not considered wasted until the waste is documented and medication is destroyed NEVER waste controlled substance in RED Container (Sharps Container)

Narcotic Waste Proper Documentation of Controlled Substances ALL narcotic waste MUST be reconciled. A report of un-reconciled waste will be sent to manager for investigation. This screen shows OUTSTANDING WASTE and must be completed at the end of shift. This screen shows PATIENT LIST and it shows ALL undocumented medication issues. It MUST be completed at the end of each shift

Narcotic Waste No personal items can be taken into the Medication Room ALL wasted medication MUST be documented at the time the medication is wasted. No personal items can be taken into the Medication Room (No back packs, purses, fanny packs, etc..)

Pass to the Right -Pass to the right: Is a “buddy system” which requires the licensed nurse to pass the MAR (medication administration record) to the next licensed nurse for a double check of the MAR to ensure all signatures/initials are present. -Medication must be signed at time of administration: if medication is administered outside of 1 hour window, the nurse must document the exact time the medication was given.

Ominicell refill Omnicell can be refilled by a Pharmacist or pharmacy technician when the Pharmacist is in the building.

Medication Labels Medication labels must be legible and accurate a all times. Any changes in dosage requires an order “Change” sticker until relabeled by pharmacy. Stickers must be placed by the Licensed Nurse noting the order.

Hand Hygiene CCC/PSA staff must perform hand hygiene before and after Resident care and when soiled. All staff must use proper hand hygiene which includes washing hands with soap and water and/or use of hand sanitizer. This includes washing hands after removing gloves.

Glove Disposal Blue gloves must be thrown in the proper trash receptacle which contains a liner. Gloves must be placed in the trash, never on the floor and proper hand hygiene must be performed before gloving and after removing gloves.

TPN Label RNs must initial the TPN label upon hanging the TPN bag. The Label must include: Initials, date and time bag was hung. Initials: . Date: . Time: .

Thank You