Survey Success
How are patients and families informed of their rights and responsibilities
Bill of Rights (Registration and posted)
Why do we post isolation signs on patient's door
To alert staff/visitors and EVS to know what type of PPE to wear and how to clean the room properly
Where is your nearest eye wash station
Varies per unit
What should you do if you find expired items in the stock room
Place in Orange waste bag
How long should you perform Hand Hygiene
20 seconds
An H&P within ___ days of the procedure date is required
30 days
How often should a patient be offered toileting, food, drink when in medical restraints
Every 2 hours
If asked a question by a surveyor, you should volunteer extra information to show how well prepared you are
No- only answer questions you are asked
How often do you clean the glucometer
after every patient use (vigorously scrub w/bleach wipes)
If a temperature is out of range, what do you need to include on the temperature log
The ACTION taken to correct the issue
Can a family member or friend be used to translate for a patient
No- Must use Language Line
Should you test the Life Pak plugged or unplugged
Unplugged- to ensure that the Life Pak is charged
What note must be on any patient record after an invasive procedure, and before the patient moves to the next level of care
A brief operative note
What alert should be called if a patient has a change in their condition
Rapid Response
What is AIDET
A specific form of communication between patient and care giver (A= Acknowledge, I= Introduction, D= Duration, E=Explanation, T=Thank you)
How long are glucometer strips good for once opened
5 months
These should be cleaned every 6 months or after every isolation patient
privacy curtains
This type of safety exercise prepares and keeps employees, patients, and visitors safe in the event of loss of power, potential disease outbreaks, or other unexpected events
Emergency or disaster drills
Where is your nearest fire alarm and extinguisher
Varies by unit
When is medication reconciliation required
On admission, transfer to a different level of care, and at discharge
It is ok to use supplies up to 6 months after their expiration date
No- all expired items should be tossed in orange return bag
What does TJC stand for
The Joint Commission
How long is glucometer test fluid good for once opened
3 months
True or False: Ripped or torn furniture can temporarily be taped or cushions turned over while waiting for it to be replaced
False
What is the number called for any Chippenham code
*31111
How are patients assessed for fall risk
Morse Fall Scale Score (hx falls, gait/transferring, mental status, secondary dx, IV/O2 tubing, meds)
What is the difference between an RCA and an FMEA
RCA (Root Cause Analysis) is done in a response to an adverse event
FMEA (Failure Mode Effect Analysis) is done proactively to prevent an adverse event
It is ok to hang your isolation gown by the patient's door and reuse it to save money as long as it's not soiled
No-must dispose of after each use
What is TJC process of following a patient's experience of care, treatment or services throughout the healthcare delivery process
Tracer
A glucometer QA test must be performed how often
Every 24 hours
True or False: Hand sanitizer is the proper hand hygiene product for C-Diff contact
False-only soap and water can be used in this instance
Where can you find the document that contains detailed information about a specific chemical and what is it called
SDS (Safety Data Sheet) and can be found on the Intranet
This program/system is used to report all adverse events and near misses
Vigilance
What is your unit's process improvement projects and where can the data be found
Varies via unit
True or False: If you only enter the room to converse with your patient and do not touch anything, you do not have to perform hand hygiene
False- hand hygiene must be performed anytime you enter or leave a room
When speaking with a Joint Commission surveyor, if you don't know an answer, take a guess and sound confident
No- Say " I don't know but I will find out"
Who is your Director of Infection Prevention
Marly Fieldhouse
True or False: Normal Saline needless syringes do not have to be locked up when not in use
False
Who is responsible for ambulating the patient for the first time post joint surgery
Nurse or Physical Therapist
What is Informed Consent
Process in which a health care provider educates a patient about the risks, benefits and alternatives to a given procedure, intervention or treatment plan
What performance improvement goals have been met or not met on your unit
Varies by unit
Who needs to wear an ID Badge and where must you wear it
Everyone must wear ID Badge and it needs to be visible and placed from the waist up
What should you do when it is announced that a surveyor has arrived onsite
Sweep your unit
How long should you perform hand hygiene with hand sanitizer
At least 20 seconds or until it is dry
True or False: It's ok to leave lancets, glucometer strips in a basin on the dyna-maps so they are there when you need them
False
How do you protect patient information
Log off computer when not in use, Do not discuss patients in public areas, Provide privacy when speaking with patients and families, Store patients information where it cannot be viewed by public, Dispose of confidential documents in appropriate bins
When should a suicide risk assessment be performed
On admission-
if positive then every shift, as needed and before discharge
If negative then as needed
How do we measure patient satisfaction
HCAPS through Press Ganey
How often should a restrained patient be assessed for discontinuation of restraints
Ongoing