Documentation
Commonly Asked Survey Questions
Low-hanging fruit
Telemetry
Infection Prevention
100

How often are nurses supposed to document on/update the patients care plan?

Every shift.

100

What does the fire safety acronym "PASS" stand for?

Pull, Aim, Squeeze, Sweep

100

Where are "full" oxygen tanks stored?

clean supply/storage room

100

How many minutes are allowed from the time the telemetry order is placed to the time the patient is placed on telemetry?

30 minutes

100

What are the REQUIRED elements of PPE for any staff member entering a room with contact precautions?

Gloves, gown

200

How often (what intervals) are nurses REQUIRED to document vital signs during blood transfusions per facility policy?

at the beginning of the transfusion, at the 15-minute mark, and after the transfusion is complete.

200

When do glucometer strips expire?

check the written expiration date/6 months after opening strips

200

What are 3 fall risk prevention strategies for a high fall risk patient?

bed/chair alarm, yellow wrist band, yellow fall risk socks, bed locked and in the lowest position, yellow fall risk sign above the outside of the door, high fall risk magnet on doorframe, call lights/belongings in reach, clutter-free floor

200

If the patient suddenly has leads come off, how long do they have to notify the primary nurse?

2 minutes

200

What are 3 things to look for when assessing a central line dressing?

clean/dry/intact, dated/labeled, biopatch blue side facing up, biopatch making a fully enclosed circle around the insertion site

300

How much time does the nurse have to relay a critical lab value to the provider and document under manage/refer/contact/notify?

30 minutes

300

Where do you find all policies and procedures?

PolicyStat

300

Where are medications wasted?

Cactus

300

If the primary nurse does not answer the phone or does not fix leads within 2 minutes, who is the telemetry tech supposed to notify next?

CNC

300

What type of precautions should a patient be on if you are ruling out tuberculosis?

airborne precautions

400

At what intervals are nurses supposed to complete documentation for non-violent restraints?

Every 2 hours

400

How can you identify emergency power outlets?

They are red.

400
What is allowed to be stored under sinks?

Absolutely nothing!

400

How long are leads allowed to be off before a tele alert is called?

Tele alerts are to be called within 5 minutes of leads coming off

400

What is the "wet time" of purple sani-wipes?

2 minutes

500

If a patient has a CIWA score of 13 before medication, what level of care are they recommended to be in per our facility policy

PCU/stepdown level of care

500

What does a "code pink" stand for? And what do staff do when it is called overhead?

Infant or child abduction. Follow facility protocol as found on PolicyStat and easily accessible on the emergency cardex at the nurse's stations.

500

If you dont know an answer to a question the surveyor is asking you, what is an acceptable response?

Let me find that answer for you *go find charge nurse, manager, or director*

500

What must occur between the nurse and the telemetry tech to ensure completion/resolution of escalation?

Closed loop communication

500

What is the purpose of a red seal on a foley catheter?

To maintain a closed, sterile circuit and prevent catheter associated UTIs (CAUTIs)