Regulatory Body Fun Facts
This is TJC's governing body.
What is CMS?
This must be done upon entering and exiting patient rooms.
What is hand hygiene?
This must be completed by providers involved to confirm the correct patient, procedure, and site.
What is time out?
Physicians should document this note within 24 hours of admission.
What is H&P?
What is every 24 hours?
What is three years?
Used PPE should be disposed here.
What are biohazardous waste bins?
This must be completed and signed prior to a procedure.
What is informed consent?
This must be done prior to PO intake.
What is swallow screen?
These must be tried prior to the use of restraints/seclusion.
What are alternative/less restrictive interventions?
Alongside TJC, this organization plays a key role in regulating California healthcare facilities to ensure compliance.
What is the California Department of Public Health (CDPH)?
Note: CDPH also works often with CMS.
This is done as best practice every 24 hours to reduce hospital-acquired infections (HAIs).
What is CHG bathing?
What are name and role?
This team of nurses can be called to respond quickly to acute changes in patient condition.
What is the Response Team?
*This team includes the Critical Care Response Team and Acute Care Response Team.
Violent restraints must be renewed at this frequency.
What is every 4 hours? (for patients over the age of 18)
What are sentinel events*?
*Sentinel events: patient safety event that reaches a patient and results in death, severe harm, or permanent harm.
This team is responsible for the surveillance, prevention, and control of healthcare-associated infections (HAIs) and other infectious diseases.
What is IPCD (Infection Prevention and Control Department?)
This should be used to mark the procedural site.
What is a marker?
All patients in-hospital must have access to this.
What is food?
Patients should NOT be in restraints at this time.
What is death?
These two agencies are notified when a death in restraints occurs.
What are CDPH and CMS?
Green Curos caps should NOT be used on these types of lines.
What are dialysis catheters?
Per current policy, surgical marking includes this.
What are the initials of the LIP/APP performing the procedure?
These must be removed from patients receiving respiratory therapy.
What are smoking materials?
These 7 elements must be assessed and documented every 2 hours when patients are in non-violent restraints.
What are:
1) Safe positioning
2) Skin & circulation
3) Mental status/level of agitation
4) Reposition & range of motion
5) Fluids & food
6) Elimination
7) Alternative interventions?