1. March 26, 2015 Ashley Kish ENVIRONMENT OF CARE RISK REDUCTION PROGRAM

2. identifies, evaluates and corrects physical plant issues (environmental threats) and unsafe practices that present an unacceptable risk to patients, staff, visitors and volunteers. POLICY

3.  The Safety Committee is charged with the responsibility of overseeing this program, and identifying and developing appropriate Plans of Action.  Using a 5-point scale, identifies and rates all known environmental deficiencies and problems determined to present a threat of physical injury to persons; damage to property or a threat to general safety.  Plans of Action to minimize and/or eliminate identified risks are developed and implemented, as appropriate.  When a risk poses an imminent threat to the safety or security of patients/staff, an interim plan of action will be developed by program management and unit supervisors for immediate implementation.  The Safety Coordinator will document findings, and keep written records of all completed assessments. PROCEDURE

4. 5 point scale 5 – highest risk; isolated area with incident history 4 – high risk, non-isolated area with incident history 3 – intermediate risk, no incident history, potential for harm 2 – low risk, no incident history, supervised area 1 – no risk, or such minor risk as not to be a serious consideration RISK ASSESSMENT CRITERIA

5. Developed by the Safety Committee and outline the most efficient and expedient course to be taken. Developed following the criteria below:  Problem identification  Analyze cause of problem  Develop alternative solutions  Recommendation of plan of action  Review and Approval of plan of action  Implementation and Monitoring of Results Plans of Action are reported to Quality Council for review and approval, then to the Executive Policy Team for final review and approval. PLANS OF ACTION

6.  When staff become aware of a new unrecognized or unidentified risk, it is their responsibility to immediately notify their supervisor/chain of command.  Supervisors are responsible for notifying the appropriate department to have the risk addressed (Health & Safety, Plant Operations, etc.)  An interim Plan of Action must be developed until the risk has been mitigated.  The priority for completing work orders is tied to the level of risk posed.  Every unit has been provided an Environment of Care Risk Reduction Manual, which is specific to that unit and should be readily available in the Nursing Station; The Environment of Care Risk Reduction Manual is not interchangeable between units. REPORTING UNIDENTIFIED RISKS

7. Safety Alert Program  Safety alerts with newly identified hazards will be emailed to all employees.  Unit supervisors will print a copy of the safety alert to post in a conspicuous location, thereby ensuring all staff has access to alerts.  Safety alerts will also be shared at each inter-shift meeting with all staff.  All alerts will include: photos and/or language describing the hazard and steps to take to mitigate the hazard. Training  Conducted as part of New Employee Orientation  Training on the Environmental Risk Assessment and Risk Reduction Program is mandatory once a year as part of the Health and Safety Monthly worksite training for all staff  Health and Safety will provide instructional cover letter to units with new identified risks to include interim plan of action until risk is corrected.  Program Management will ensure all staff is trained on the new risk and the interim plan of action. EDUCATION AND AWARENESS

8. POST TEST

9. REVIEW OF THERAPEUTIC DIETS

10. Therapeutic Diet – Any diet ordered for control or treatment of a medical condition. Nutritional Management  health maintenance/health promotion  acute or chronic conditions  allows us to determine whether a nutrition intervention/diet is working for the patient WHY IS IT IMPORTANT TO FOLLOW DIETS?

11. REGULAR  for patients without special nutritional needs or medical problems 2000/1800/1600  for patients in need of weight loss and/or weight management CALORIE CONTROLLED DIETS

12. SOFT  for patients with chewing deficits secondary to poor dentation GROUND  for patients with swallowing difficulty, choking risk, progressing to regular diet PUREE  for patients with mechanical deficits with chewing and/or swallowing LABEL THESE CORRECTLY! MODIFIED CONSISTENCY DIETS

13. VEGETARIAN  excludes all meat, except fish and shellfish VEGAN  excludes all animal products, which includes meats, fish, shellfish, dairy, eggs 2 g SODIUM  reduces the sodium content of tissues and prevents accumulation of excess fluid; may be prescribed during renal disease, cirrhosis, hypertension, congestive heart failure RENAL  for patients with a need for increased protein, reduced sodium, potassium and phosphorus; prescribed during end stage renal disease while undergoing dialysis.  2 g sodium ≠ renal LABEL THESE CORRECTLY! SPECIAL DIETS

14. QUESTIONS???