Falls
How do you know a patient is a high fall risk?
Epic fall precautions trigger, Epic Morse Fall Risk assessment, falling star program 'RED' star.
How do you know a patient is at risk for pressure injuries?
Refer to the Braden score!
Limited mobility, poor skin perfusion or circulation, medical conditions like diabetes, nutrition deficits, cognitive impairment, medications, environmental factors.
What are some non-pharmacological interventions we use before considering medication changes?
Documentation (behaviors, activities, restoratives, refusals, interventions and effectiveness, etc.) environmental adjustments, comfort measures.
What should be done if shared equipment is used between residents?
Disinfect before and after each use
Who is responsible for completing restorative programs and documentation?
The resident's CNA.
Name 5 interventions you do to prevent falls.
Supervision, alarms, proper footwear, DME as care planned in place, falling star program.
Who is responsible for completing a weekly full skin assessment?
The licensed nurse.
What documentation is required when a resident starts or changes a psychoactive medication?
Notify guardian immediately for consent with risk and benefits explained. Use smart phrase .psmhpsychoactiveRB for note documentation.
What is enhanced barrier precautions and how do you know someone is on it?
When do you and how do you use your badge to clock in and out?
At the Kronos Kiosk.
Immediately upon arrival and departure of shift.
For breaks.
When do you get vital signs for a patient that fell?
Immediately - before you move them.
Name 5 practices we follow to prevent pressure injuries.
Frequent repositioning, Z-flex boots, air mattresses, cushions, and preventative skin treatments.
How and when do you order medications? Script and stock.
At least 10 days prior to running out.
Stock > paper request
Prescription > Epic secure chat
What are the hand hygiene expectations for all staff?
Before:
After:
Other Situations:
Alcohol-Based Hand Sanitizer (ABHS):
Soap and Water:
If you do not know the correct process or have questions on a process, what do you do?
Ask coworker & use nursing playbook, consult charge nurse then ask your manager.
What is the falling star program and where can you find it?
What should you do if you notice a malfunctioning air mattress or missing cushion?
Contact maintenance and/or therapy immediately and notify supervisor.
Your MAR indicates your patient is due for a medication that is not on hand. What do you do?
Contact your supervisor, file HRP, and hold medication.
How often should high-touch surfaces be disinfected in resident rooms?
Every shift and as needed
What were the most recent CMS survey tags?
F550 Resident Dignity
F628 Transfer and Discharge Documentation
F755 Medication Administration
F812 Food Safety
When was the last fall at our facility? Can you name who?
Confidential* R10 9/26, L8 10/13, F1 9/15, E6 10/14
What is a Braden Score and what is the purpose of it?
Widely used clinical tool for assessing a patient's risk of developing pressure injuries (also known as pressure ulcers or bedsores).
It evaluates six key areas that influence skin integrity and pressure injury risk. The lower the score, the higher the risk for pressure injury development.
On admission, weekly, and with any significant change in condition.
Name the 6 rights of medication administration.
Right patient
Right medication
Right dose
Right route
Right time
Right documentation
What are the interventions for preventing CAUTIs?
2 nurse aseptic procedures, proper catheter care q shift, ensure bag is below bladder and off the ground w/ cover in place, change catheter according to orders, hydration station, and monitoring for clogging.
What are YOU doing or could do to support our journey to 5 stars?
You tell me.