Infection Control
The frequency that hands should be washed (with either soap and water or hand sanitizer).
What is prior to room entry, upon room exit, between resident care, after toileting (self or resident), before feeding/eating, when soiled, etc.
The issue(s) with Image 1
What are lift on the wrong side of hallway (in fire lane), UV box not stocked with paper bag, wipes, and hand sanitizer. Laundry cart should also not be stagnant >5 minutes (but cannot tell from this picture).
What you would do if you saw a resident being abused
What is ensure resident safety (remove resident from the situation) and immediately report to your supervisor/chain of command.
What should be done when you notice a call bell not working.
Enter worxhub order for engineering and give the resident the ability to call for assistance in the meantime (bell, rounding Q 15 min, etc.)
The frequency that QAPI meetings are held
What is monthly
PPE should be applied in this order (include gown, mask, gloves, and eye protection)
The issue(s) with Image 2
What are clean supplies being stored, blood pressure cuff not disinfected and just left on the counter, signage on the cabinet that belongs in the file cabinet on the floors (after being disinfected).
Where you would find information about what a resident is able to do for themselves
What is care-card and/or careplan
The person that should be notified of a resident complaint/grievance
What is the social worker
The name and explanation of the facility's current performance improvement project
What is the Falling Leaves and a project to assist in decreasing falls in the most at high-risk residents. A falling leaf symbol is placed on the doors of the residents on the program, a list is placed at the nursing station, and an email is sent biweekly regarding the project. We then know which residents should have more frequent checks for safety.
PPE should be removed in this order (include gown, gloves, mask, eye protection)
What is Gloves->Gown->Mask->Eye Protection
(Eye protection should be doffed at doffing station)
The issue(s) with Image 3
What is supplies on the floor
The frequency if repositioning residents who are confined in a bed or wheelchair.
What is at least every 2 hours for a resident who is in the bed and at least every 15 minutes for a resident who cannot move themselves in a wheelchair.
The person who is able to order emergent restraints for resident safety.
What is the intranet
How you should distribute laundry on your unit
What is by using a cart and ensuring the cart stays covered. DO NOT hold laundry close to your body.
The issue(s) with Image 4
What are resident information on the cart (HIPAA violation) and an open container of pudding not dated.
What you would do if your resident refused a bath
CNA-What is reapproach at a later time and notify nurse.
Nurse-What is educate the resident on risks associated, attempt to find a better schedule to fit their needs, and document refusal and education given
The chain of command involves these individuals in this order.
What is CNA->Charge Nurse->Nurse Manager/Supervisor->ADON->DON->Administrator->Vice President->CEO
3 of the things you should first do when you are notified the surveyors are in the building
CNAs: What is round on rooms to ensure beds are locked, ice and water is available, unit and rooms are clean and tidy, spa room is compliant, etc.
Nurse: Check fridge temp logs for missing entries, check med cart for expired meds and ensure open containers are dated, check treatment boxes for compliance, round unit to ensure cleanliness and compliance, etc.
The location of the blood spill kit
What is in the supply room
The issue(s) with Image 5
What are linen out, chemicals out, and dirty clothes bagged on hamper
The requirements for staff prior to performing any care for a resident
What is knock on the door and wait for permission to enter, introduce self if needed, and explain to the resident what is being done during the care so the resident will be at ease. This is due to a resident's right to know what is going on and privacy.
The compliance Officer
Who is Russell Gardner
3 members who must participate in the QAPI Committee
Who are the Infection Preventionist, Medical Director, DON, Administrator, CNA. Representatives from other departments are also recommended.