1. NCU Mock Survey Education Module: Unlicensed Staff
Brandy Shannon, RN, MSN, DSD
Clinical Educator
January 2015

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

3. Objectives:
Staff will have a better understanding of the importance of compliance related to policies and procedures of the organization.
Staff will be knowledgeable regarding the following topics:
Dignity/Resident Rights
Closed Records
Assessment/Documentation/
Care Planning
Disaster Preparedness Emergency Procedures
Weights
6. Changes in condition
7. Infection Control
8. Provision of Respiratory care: As it applies to the Licensed Nurse.
9. Medication Management/Pharmacy Services.

4. Dignity & Residents Rights
Knock prior to entering room and pull curtains to provide privacy.
Policy No: : Patient Rights & Responsibilities; Patient Relations
Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms.

5. Dignity & Residents Rights
It is the healthcare worker’s responsibility to ensure the Resident’s rights are being observed.
The healthcare worker must knock prior to entering the Resident’s room and pull curtain for privacy prior to providing care.

6. Closed Records Only approved abbreviations may be used
Policy # U-1 page 1: Abbreviations and Symbols (Policy)
It is the policy of this facility to utilize only approved abbreviations and symbols to prevent error and enhance the safety of all residents.

7. Closed Records
Proper documentation is to be completed regarding discharge/transfer/room changes.
Policy # F-3 page :Discharge/Transfer/Room Changes.
The interdisciplinary team will be responsible for the planning, review of discharge potential, coordination of necessary treatments, and determination of need for continued stay in the facility, in accordance with regulatory guidelines and facility Utilization Review processes.
Residents will be transferred or discharged from the facility according to OBRA and regulatory guidelines governing transfer/discharge.

8. Disaster Preparedness
Meal plan: prepare for FOUR days worth of meals in the event of a disaster. All actions will be directed by the Hospital Command Center. NCU Population Assumptions: 88 Patients, 5 patient with food by mouth, 70 Essential Staff, 10 visitors.f Meals: Phase one: Day one and Day two-meals will be prepared according to perishable food menus form items on hand in Main Kitchen. Phase two: Day one and Day two Meals will be prepared according to menus from Rehydrated products, stored in the facilities storage area.

9. Disaster Preparedness
Enteral Feeding: A Five day supply of Tube Feeding/Supplements is located in the main kitchen storage room as well as on all three NCU units. Water (Stored in the Facilities Storage Area) Drinking Water Two 16.9 oz bottles of water available per person per day for four days. Flushing water Two 16.9 oz bottles of water available per tube feeding patient per day for five days. Rehydration water Water to rehydrate food and beverage for phase two menus

10. Weights
Lack of consistent documentation of residents weights (increase & decrease over 5 lbs) without notification to dietary, physician, and responsible party. Review of process needed as well as completion of form.
Policy #O-15 page 1 of 1: Weight Variance Monitoring
Scales will be re-balanced by staff prior to obtaining each resident’s weight.

11. Weights Unusual or significant weight variance includes the following:
Gain or loss of 5 lbs or 3 % or more in one month when resident weights over 100 lbs.
Gain or loss of 3lbs or 3 % or more in one month when the resident weighs 100 lbs or less.
Gain or loss of 7.5% or more weight in 3 months for any resident.
Consistent weight gain or loss over several months or 10 % or more of weight variance in 6 months.
Unusual or significant weight losses or gains will be reported to the physician and responsible party.

12. Weights
Unusual or significant weight loss or gain is to be reported immediately to charge nurse, Clinical Manager/Director, Physician, Dietary and responsible parties.
All required documentation is to be complete.

13. Changes of Condition
No documentation to reflect notification to family of Residents change in condition. No date on documentation of physician notifications.
Policy #G-3 pages 1 & 2: Change in Resident Condition/ Notification of Changes.
It is the policy of this facility that all changes in resident conditions and other changes, as required by regulations, will be communicated to the physician and family or legal representative.

14. Changes of Condition
Changes in condition will be reported immediately to charge nurse, physician and responsible party.
Upon notification to the physician proper documentation is to be completed, which also includes the date and time the physician was notified.

15. Infection Control Staff to be re-educated on the use of PPE.
Policy #L-8 pages 1-5: Infection Control.
To prevent the spread of pathogens among healthcare workers and residents by direct or indirect contact with high risk body fluid.

16. Infection Control
Standard precautions should include: Using appropriate personal protective equipment (PPE) when there is potential exposure to infectious substances.
Personal Protective Equipment (PPE)
PPE includes: Gloves, protective face and eyewear, gowns and other protective apparel.
Gloves must be changed between resident contacts, between tasks and procedures on the same resident after contact with material that maybe contaminated.
Remove gloves after each use, before touching non-contaminated items and environmental surfaces and before going to another resident.

17. Infection Control
Standard precautions must be observed by all healthcare staff. PPE is not to be worn outside the resident’s room, as this poses an infection control risk/hazard.
All PPE is taken off prior to leaving the residents room and staff are expected to perform hand hygiene upon removal of PPE.

18. Medical Records-General
Real time documentation is required; do not wait untill the end of the shift to document.
Policy # G-6 Pages 1-2: Charting, Guidelines
All charting should be done as soon as possible after a given event.
When making a late entry, write the current date, time and “late entry for DATE.” late entries will be written as soon as possible.

19. Medical Records-General
Documentation must be accurate, signed and dated using black ink.
Policy #G-7 pages 1-2: Documentation in the medical Record, Legal
A clear, concise accurate, legible and chronological written history of the resident’s stay will be documented in accordance with State and Federal guidelines and joint Commission standards.
It is best to use a medium point black ball point pen.
The medical record should not contain irrelevant observations, personal opinions, teaching notes, or other entries that are unrelated to the resident’s care.

20. Thank You