Download Patient-Focused Care Practices at your Facility

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FORMS & TOOLS
The following pages contain practical tools for implementing
patient-focused care practices at your facility.
OASIS-C
Integumentary Status ........................................86
H1N1 (Swine Flu)
Patient Handout (English) ..................................89
Patient Handout (Spanish) ................................91
Leg Ulcers
Clinical Fact Sheet: Quick Assessment
of Leg Ulcers ......................................................93
Infection Prevention and Control
Long-Term Care Audit ........................................95
Bariatrics
Bariatric Assessment: Home Care/Long-Term
Care Facility ....................................................101
Improving Quality of Care Based on CMS Guidelines 85
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OASIS-C Integumentary Status
This checklist is part of the new OASIS-C guidance from the Centers for Medicare
& Medicaid Services. OASIS-C went into effect at the end of 2009. For a step-by-step
explanation of this portion of OASIS-C, turn to the article on page 29.
OASIS-C
INTEGUMENTARY STATUS
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure
Ulcers?
0 - No assessment conducted [ Go to M1306 ]
1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,
without use of standardized tool
2 - Yes, using a standardized tool, e.g., Braden, Norton, other
(M1302) Does this patient have a Risk of Developing Pressure Ulcers?
0 - No
1 – Yes
(M1306) Does this patient have at least one Unhealed (non-epithelialized) Pressure Ulcer at Stage
II or Higher or designated as "not stageable"?
0 - No [ Go to M1322 ]
1 – Yes
(M1307) Date of Onset of Oldest Unhealed Stage II Pressure Ulcer identified since most
recent SOC/ROC assessment:
__ __ /__ __ /__ __ __ __
month / day / year
UK - Present at most recent SOC/ROC assessment
NA - No new Stage II pressure ulcer identified since most recent SOC/ROC assessment
86 Healthy Skin
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OASIS-C Integumentary Status
Forms & Tools
OASIS-C
INTEGUMENTARY STATUS (cont’d.)
(M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter
“0” if none; enter “4” if “4 or more”; enter “UK” for rows d.1 – d.3 if “Unknown”)
Stage description – unhealed pressure
Number Present
Number of these that were
ulcers
present on admission
(most recent SOC / ROC)
a. Stage II: Partial thickness loss of dermis
presenting as a shallow open ulcer with red
pink wound bed, without slough. May also
present as an intact or open/ruptured serumfilled blister.
b. Stage III: Full thickness tissue loss.
Subcutaneous fat may be visible but bone,
tendon, or muscles are not exposed. Slough
may be present but does not obscure the
depth of tissue loss. May include
undermining and tunneling.
c. Stage IV: Full thickness tissue loss with
visible bone, tendon, or muscle. Slough or
eschar may be present on some parts of the
wound bed. Often includes undermining and
tunneling.
d.1 Unstageable: Known or likely but not
stageable due to non-removable dressing or
device
d.2 Unstageable: Known or likely but not
stageable due to coverage of wound bed by
slough and/or eschar.
d.3 Unstageable: Suspected deep tissue
injury in evolution.
Directions for M1310 and M1312: If the patient has one or more unhealed (non-epithelialized)
Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension
(length x width) and record in centimeters:
(M1310) Pressure Ulcer Length: Longest length “head-to-toe” | ___ | ___ | . | ___ | (cm)
(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to
the length | ___ | ___ | . | ___ | (cm)
(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the
deepest area | ___ | ___ | . | ___ | (cm)
(M1320) Status of Most Problematic (Observable) Pressure Ulcer:
0 - Re-epithelialized
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
NA - No observable pressure ulcer
Continued on page 88
Improving Quality of Care Based on CMS Guidelines 87
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OASIS-C Integumentary Status
OASIS-C
INTEGUMENTARY STATUS (cont’d.)
(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler
as compared to adjacent tissue.
0 1 2 3 4 or more
(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:
2 - Stage II
3 - Stage III
1 - Stage I [Go to M1330 at SOC/ROC/FU ]
NA - No observable pressure ulcer
4 - Stage IV
(M1330) Does this patient have a Stasis Ulcer?
0 - No [ Go to M1340 ]
1 - Yes, patient has one or more (observable) stasis ulcers
2 - Stasis ulcer known but not observable due to non-removable dressing [ Go to M1340 ]
(M1332) Current Number of (Observable) Stasis Ulcer(s):
1 - One
2 - Two
3 - Three
4 - Four or more
(M1334) Status of Most Problematic (Observable) Stasis Ulcer:
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
(M1340) Does this patient have a Surgical Wound?
0 - No [ Go to M1350 ]
1 - Yes, patient has at least one (observable) surgical wound
2 - Surgical wound known but not observable due to non-removable dressing [ Go to M1350 ]
(M1342) Status of Most Problematic (Observable) Surgical Wound:
0 - Re-epithelialized
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other
than those described above that is receiving intervention by the home health agency?
0 - No
1 - Yes
88 Healthy Skin
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Forms & Tools
H1N1 Patient Handout
H1N1 (Swine Flu)
What is H1N1 flu?
H1N1 influenza, or swine flu, is a respiratory
illness caused by type A influenza viruses. This
virus was originally referred to as “swine flu”
because it was thought to be very similar to flu
viruses that normally occur in pigs (swine) in
North America. H1N1 flu was first detected in
people in the United States in April 2009.
How does H1N1 flu spread?
H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu viruses
spread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop and
for seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touching
something with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.
What are the symptoms of H1N1 flu?
The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body
aches, headache, chills and fatigue. Diarrhea and vomiting may also be associated with
H1N1 flu. Most people with the virus have recovered without needing treatment, but
hospitalizations and deaths have occurred.
H1N1 Symptoms
• Headache
• Fever
• Fatigue
What should I do if I think I have H1N1 flu?
If you have flu symptoms, stay home and avoid contact with other people to avoid
spreading your illness. It is recommended that you stay home for at least 24 hours after
your fever is gone, or if possible, until your cough is gone. If you have severe illness or
you are at high risk for flu complications, contact your health care provider.
He or she will determine whether testing or treatment is needed.
• Chills
Seek emergency medical care for any of the following warning signs:
• Body aches
• Runny or
stuffy nose
• Sore throat
• Cough
In children:
In adults:
•
•
•
•
•
•
• Difficulty breathing
or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with
fever and worse cough
Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with
fever and worse cough
• Severe or persistent vomiting
Page 1
Text courtesy of NursingCenter.com.
Images courtesy of Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
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anatomical.com
5mcc.com
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H1N1 Patient Handout
How is H1N1 flu treated?
The CDC recommends the use of oseltamivir (brand
name Tamiflu) or zanamivir (brand name Relenza) to
treat and/or prevent swine influenza. These antiviral
medications may also prevent serious complications.
For treatment, antiviral drugs work best if star ted
within 2 days of symptoms.
What can I do to prevent H1N1 flu?
You can reduce your risk of contracting and spreading swine influenza
and other influenza viruses by:
• Coughing or sneezing into
your arm; avoiding close
contact with people who have
respiratory symptoms such as
coughing or sneezing
• Not touching your eyes, nose, or
mouth because this is how germs
get into your body
• Staying home when you're sick
and getting as much rest
as possible
• Keeping surfaces and objects
(especially tables, counters, doorknobs, toys) that can be exposed
to the virus clean
• Washing your hands often
with soap and water for
15-20 seconds; using
alcohol-based hand cleansers
is also acceptable
• Practicing other good health habits,
including getting plenty of sleep,
staying active, drinking plenty of
fluids, and eating healthy foods
Lisa Morris Bonsall, MSN, RN, CRNP
Page 2
90 Healthy Skin
Text courtesy of NursingCenter.com.
Images courtesy of Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
Check with your healthcare
provider to see if the
H1N1 vaccine is right for you.
nursingcenter.com
anatomical.com
5mcc.com
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Forms & Tools
H1N1 Español por los Pacientes
Virus de la influenza A subtipo H1N1
(anteriormente llamado de la «gripe porcina»)
¿Qué es la gripe por H1N1?
La gripe por H1N1, originalmente llamada
«gripe porcina», es la enfermedad respiratoria que
causa la infección por el virus de la influenza A
subtipo H1N1. A este virus originalmente se le llamó
virus de la «gripe porcina» puesto que se pensó que
era muy similar a los virus que causan gripe en los
cerdos (porcinos) en Norteamérica. El virus de la influenza
A subtipo H1N1 fue detectado por primera vez en humanos
en los Estados Unidos de Norteamérica en abril del 2009.
¿Cómo se propaga la gripe por H1N1?
La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otros
virus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomas
y durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona se
infecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comer
carne de cerdo no causa gripe por H1N1.
¿Cuáles son los síntomas de la gripe por H1N1?
Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz con
mucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoría
de las personas que han tenido el virus se han recuperado sin necesitar tratamiento, pero
ha habido otras que han necesitado hospitalización, y también otras que han muerto.
Síntomas de A(H1N1)
• Dolor de cabeza
• Fiebre
• Fatiga
¿Qué debo hacer si pienso que tengo gripe por H1N1?
Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto con
otras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lo
menos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después
de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto
riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención
médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento.
• Escalofríos
• Nariz con
mucosidad o tupida
• Dolor de garganta
• Tos
• Dolores corporales
Busque atención médica de urgencias si presenta cualquiera de los
siguientes signos (señas) de alarma:
En niños:
En adultos:
•
•
•
•
•
•
• Dificultad para respirar o sensación de «falta de aire»
• Dolor o sensación de presión en el pecho o en
el abdomen
• Mareo súbito
• Confusión
• Vómito intenso o persistente
• Los síntomas como de gripe mejoran pero luego
reaparecen con fiebre y tos más fuerte.
Respiración acelerada o dificultad para respirar
Tonalidad morada en la piel
No está tomando suficientes líquidos
No se despierta o no responde a las acciones
Está tan irritable que no quiere que lo alcen
Los síntomas como de gripe mejoran pero
luego reaparecen con fiebre y tos más fuerte.
• Vómito intenso o persistente
Página1
Texto por cortesía del centro NursingCenter.com.
Imágenes por cortesía de Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
nursingcenter.com
anatomical.com
5mcc.com
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H1N1 Español por los Pacientes
¿Cómo es el tratamiento para la gripe por A(H1N1)?
Los Centros para el Control y la Prevención de Enfermedades de los EE. UU.
(CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o de
zanamivir (nombre de marca Relenza) para el tratamiento y la infección,
o solamente para prevenir la infección por el virus de la influenza
A(H1N1). Estos medicamentos antivíricos también pueden prevenir
complicaciones graves. Para el tratamiento, los medicamentos antivíricos
funcionan mejor si se comienzan a usar en un lapso de dos días después
de que comienzan los síntomas.
¿Qué puedo hacer para prevenir la gripe por A(H1N1)?
Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagar
otros virus de la influenza de la siguiente manera:
• Tosiendo o estornudando sobre
su brazo y evitando el contacto
cercano con personas que
presentan síntomas respiratorios
tales como tos o estornudos.
• No tocándose los ojos, nariz o
boca, pues ésta es la manera
como los gérmenes llegan hasta
nuestro cuerpo.
• Quedándose en casa cuando está
enfermo y descansando el mayor
tiempo que pueda.
• Manteniendo limpias las superficies
y objetos (especialmente mesas,
mesones, cerraduras de puertas)
que puedan estar expuestos al virus.
• Lavándose las manos con
frecuencia con agua y jabón
durante 15 a 20 segundos o
usando un limpiador para las
manos con base en alcohol.
• Practicando otros hábitos saludables;
incluso dormir bastante, mantenerse
activo, tomar líquidos en cantidad y
comer alimentos saludables.
Escrito por Lisa Morris Bonsall, MSN, RN, CRNP
Traducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP)
Página 2
Texto por cortesía del centro NursingCenter.com.
Imágenes por cortesía de Anatomical Chart Company.
Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
92 The OR Connection
Verifique con su proveedor
de atención médica para
determinar si la vacuna
contra el virus de la
influenza A(H1N1) es
adecuada para usted.
nursingcenter.com
anatomical.com
5mcc.com
History
WOCN
‹
1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C
‹
Mount Laurel, NJ 08054
‹
‹ We b s i t e : w w w. w o c n . o r g
Continued on page 94
NAILS
‹ Onychomycosis; dystrophic nails; paronychia, hypertrophy
SURROUNDING SKIN
‹ Normal skin tones
‹ Trophic changes
‹ Fissuring or callus formation
‹ Edema: with erythema may indicate high pressure
‹ Temperature: warm
WOUND
‹ Base: pink/pale; necrotic tissue variable;
‹ Depth: variable
‹ Edges well defined
‹ Exudate: usually small to moderate
‹ Wound shape: usually rounded or oblong and found over
bony prominence
(888) 224-WOCN
SURROUNDING SKIN
‹ Pallor on elevation
‹ Dependant rubor
‹ Shiny, taut, thin, dry,
‹ Hair loss over lower extremities
‹ Atrophy of subcutaneous tissue
‹ Edema: variable; atypical
‹ Temperature: decreased/cold
‹ Infection: Cellulitis
‹ Necrosis, eschar, gangrene may be present
SURROUNDING SKIN
‹ Venous dermatitis (erythematic, weeping, scaling, crusting)
‹ Hemosiderosis (brown staining)
‹ Lipodermatosclerosis; Atrophy Blanche
‹ Temperature: normal; warm to touch
‹ Edema: pitting or non-pitting; possible induration and cellulitis
‹ Scarring from previous ulcers, ankle flare, tinea pedis
‹ Infection: Induration, cellulitis, inflamed, tender bulla
Advanced age
Alcoholism
Chemotherapy
Diabetes
Hansen’s Disease
Heredity
HIV, AIDS and related drug therapies
Hypertension
Impaired glucose tolerance
Obesity
Raynaud’s Disease, Scleroderma
Smoking
Spinal Cord Injury and neuromuscular diseases
‹ Altered pressure points/sites of painless trauma/repetitive
stress
‹ Dorsal and distal toes
‹ Heels
‹ Inter-digital
‹ Metatarsal heads
‹ Mid-foot (dorsal and plantar)
‹ Toe interphalangeal joints
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Peripheral Neuropathy
Quick Assessment of Leg Ulcers
NAILS
‹ Dystrophic
WOUND
‹ Base: Pale; granulation rarely present; necrosis, eschar, gangrene (wet
or dry) may be present
‹ Depth: may be deep
‹ Margins: edges rolled; punched out, smooth and undermining
‹ Exudate: minimal
‹ Infection: frequent (signs may be subtle)
Areas exposed to pressure or repetitive trauma, or rubbing of footwear
Lateral malleolus
Mid tibial
Phalangeal heads
Toe tips or web spaces
Arterial Disease
Cardiovascular Disease
Diabetes
Dyslipidemia
Hypertension
Increased pain with activity and/or elevation
IIntermittent Claudication
Obesity
Painful Ulcer
Sickle Cell Anemia
Smoking
Vascular procedures/surgeries
WOUND
‹ Base: ruddy red; yellow adherent or loose slough; granulation tissue
present, undermining or tunneling are uncommon
‹ Depth: usually shallow
‹ Margins: irregular
‹ Exudate: moderate to heavy
‹ Infection: less common
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Advanced Age
CHF
Lymphedema
Obesity
Orthopedic Procedures
Pain reduced by elevation
Pregnancy
Previous DVT with Phlebitis
Pulmonary Embolus
Reduced mobility
Sedentary Lifestyle
Traumatic Injury
Vascular Ulcers
Work History
Arterial Insufficiency
Quick Assessment of Leg Ulcers
‹ Malleolus
‹ Medial aspect of leg superior to medial malleolus
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Venous Insufficiency (STASIS)
Clinical Fact Sheet
8:09 PM
Location
2/11/10
Assessment
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WOCN
‹
‹
Revised: November 24, 2009
Mount Laurel, NJ 08054
‹
(888) 224-WOCN
‹ We b s i t e : w w w. w o c n . o r g
‹ Cautious use of occlusive dressings
INFECTED WOUND/DRY OR MOIST NECROSIS
‹ Referral for potential surgical debridement/antibiotic therapy
OPEN WOUND/NON-NECROTIC
‹ Moist wound healing;
‹ Non-occlusive dressings
‹ Aggressive treatment of any infection
‹ Use dressings that maintain a moist surface, absorb exudates
and allow easy visualization
MEASURES TO ELIMINATE TRAUMA
‹ Reduction of shear stress and offloading of neuropathic
wounds (bedrest, contact casting, orthopedic shoes)
‹ Use of assistive devices to provide support, balance and
additional offloading
‹ Appropriate footwear
‹ Tight glucose/glycemic control
‹ Aggressive prevention/treatment of infection (debridement
of callus and necrotic tissue; pharmacologic treatment when
appropriate)
‹ Revascularizaton if ischemic
‹ Complications: Cellulitis, osteomyelitis, gangrene, Charcot
fracture
DRY, NON-INFECTED, NECROTIC WOUND
‹ Keep dry
MEASURES TO IMPROVE TISSUE PERFUSION
‹ Revascularization if possible
‹ Medications to improve RBC transit through narrowed vessels
‹ Lifestyle changes (avoid tobacco, caffeine, restrictive garments,
cold temperatures)
‹ Hydration
‹ Measures to prevent trauma to tissues (appropriate foot wear)
‹ Maintain legs in neutral or dependent position
‹ Pressure reduction for heels and toes
1 5 0 0 0 C o m m e r c e Pa r k wa y, S u i t e C
‹ Goals: absorb exudates, maintain moist wound surface
30mm Hg compression at ankle‘
‹ **See WOCN Clinical Practice Guideline for Compression Therapy
Surgical obliteration of damaged veins
Elevation of legs
Medications
Exercise
Education
Compression therapy to provide at least
NON-INVASIVE VASCULAR TESTING
‹ Capillary refill: Normal
NON-INVASIVE VASCULAR TESTING
‹ Capillary refill: Delayed (more than 3 seconds)
‹ ABI <0.9
‹ TCPO2 <40mmHG
‹ TP >30mm HG
NOTE: LEAD may co-exist with neuropathic disease
PERIPHERAL PULSES
‹ Palpable/present
PAIN
‹ Decreased sensitivity to touch; if present, pain may be
superficial, deep, aching, stabbing, dull, sharp, burning or
cool; altered sensation not described as “pain” (numbness,
warmth, prickling, tingling)
Peripheral Neuropathy
PERIPHERAL PULSES
‹ Absent or diminished
PAIN
‹ Intermittent claudication
‹ Resting; positional; nocturnal
‹ Painful Ulcer
‹ Paresthesias
Arterial Insufficiency
Quick Assessment of Leg Ulcers
8:09 PM
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MEASURES TO IMPROVE VENOUS RETURN
‹ (Provided vascular studies have ruled out significant arterial disease)
NON-INVASIVE VASCULAR TESTING
‹ Capillary Refill: normal (less than 3 seconds)
‹ ABI to rule out arterial component
PERIPHERAL PULSES
‹ Present/palpable
PAIN
‹ Minimal unless infected or dessicated
‹ Described as throbbing, sharp, itchy, sore, tender, heaviness
‹ Worsens with prolonged dependency
Venous Insufficiency (STASIS)
Clinical Fact Sheet
Forms & Tools
Perfusion
94 Healthy Skin
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Topical Therapy
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Quick Assessment of Leg Ulcers
PARTLY
IMPLEMENTED
FULLY
IMPLEMENTED
Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Long Term
Care, Home and Community Care including Health Care Offices and Ambulatory Clinics
No nail enhancements
Includes no jewellery (rings or bracelets)
Written Policies for Dress Code:
Cleaner for client equipment
Goggles/eye protection
Continued on page 96
Long Term Care Infection Prevention Audit
Alcohol-based hand rub stations
Gowns
Masks
Gloves
Protective equipment available
Written policy and procedure for client assessment
Includes: drainage, cough, fever, continence, ability to
follow hygiene measures
Client assessed before entry for risk factors (fever,
cough, diarrhea, rash, drainage)
UNIT LEVEL
Hand Hygiene Station at entrance
8:52 PM
Infection Control Signage at Entry (related to
screening for communicable diseases)
COMMENTS
2/12/10
ENTRY TO FACILITY
AREAS AND ITEMS
NOT
IMPLEMENTED
AUDIT PERFORMED BY __________________________ DATE:___________________
AREA AUDITED :_______________________________
LONG TERM CARE AUDIT
APPENDIX III – AUDIT TOOL (A)
FOR LONG TERM CARE AND COMMUNITY CARE INCLUDING HEALTH CARE OFFICES AND AMBULATORY CLINICS
INFECTION PREVENTION AND CONTROL BEST PRACTICES
N/A
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(CONTINUED)
Forms & Tools
8:52 PM
PARTLY
IMPLEMENTED
Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Long Term
Care, Home and Community Care including Health Care Offices and Ambulatory Clinics
COMMENTS
2/12/10
Signage for hand washing
Signage for alcohol-based hand rub
Signs showing how to wash hands
Signs showing How to use alcohol-based hand rub
Staff can identify when to use hand hygiene:
Before resident care
Before aseptic practices
After resident care
After contact with body fluids or mucous
membranes
After contact with contaminated equipment
Resident equipment has regular cleaning schedule
Commodes
BP Cuffs
Slings
Glucometers
Cleaners used are appropriate and used according to
manufacturer’s recommendations
concentration
contact time
Clean procedures use sterile supplies
e.g. Wound care
Catheterization
Resident Personal Care Equipment is labeled
and stored safely
AREAS AND ITEMS
LONG TERM CARE AUDIT
APPENDIX III – AUDIT TOOL (A)
NOT
IMPLEMENTED
FOR LONG TERM CARE AND COMMUNITY CARE INCLUDING HEALTH CARE OFFICES AND AMBULATORY CLINICS
N/A
INFECTION PREVENTION AND CONTROL BEST PRACTICES
FULLY
IMPLEMENTED
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Long Term Care Infection Prevention Audit
WASTE
NOT
IMPLEMENTED
PARTLY
IMPLEMENTED
Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Long Term
Care, Home and Community Care including Health Care Offices and Ambulatory Clinics
Continued on page 98
Long Term Care Infection Prevention Audit
Documentation of staff tubercline skin tests are kept
Documentation of staff immunization is kept:
Flu Shots
MMR
TDP
Hep B
HEALTHY WORKPLACE
Puncture Resistant Sharps containers are used
Written policies reflect waste segregation
Sharps containers not more than 3/4 filled
Sharps containers are accessible and safe
COMMENTS
8:53 PM
Laundry is transported in a clean manner
Soiled laundry in sealed bags
Clean in segregated manner
Laundry is sorted by staff wearing PPE
Hand hygiene is available in laundry area
Education is provided to laundry workers on
protective practice
Immunization is offered to laundry workers for
Hepatitis B
(CONTINUED)
2/12/10
LAUNDRY
AREAS AND ITEMS
LONG TERM CARE AUDIT
APPENDIX III – AUDIT TOOL (A)
N/A
FOR LONG TERM CARE AND COMMUNITY CARE INCLUDING HEALTH CARE OFFICES AND AMBULATORY CLINICS
INFECTION PREVENTION AND CONTROL BEST PRACTICES
FULLY
IMPLEMENTED
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Page 97
Forms & Tools
Improving Quality of Care Based on CMS Guidelines 97
98 Healthy Skin
(CONTINUED)
PARTLY
IMPLEMENTED
Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Long Term
Care, Home and Community Care including Health Care Offices and Ambulatory Clinics
Written policies identify notification process for
clusters of symptoms or outbreaks
Written policies and procedures exist for managing
outbreaks
Including tools for tracking cases
and a communication plan
Forms & Tools
8:53 PM
OUTBREAK MANAGEMENT
COMMENTS
2/12/10
Written policies outline work exclusions:
Dermatitis on hands
Disseminated shingles
Initial days of a cold
Diarrhea
Eye infection until treated
Written policy outlines Bloodborne Pathogen Followup (Sharps injury or blood splash)
Education is provided to staff annually on Infection
prevention and Control
Education is provided on risk assessment, routine
practices and equipment cleaning
Rate of Staff Flu vaccination year_______
Rate of Resident Flu vaccination
AREAS AND ITEMS
LONG TERM CARE AUDIT
APPENDIX III – AUDIT TOOL (A)
NOT
IMPLEMENTED
FOR LONG TERM CARE AND COMMUNITY CARE INCLUDING HEALTH CARE OFFICES AND AMBULATORY CLINICS
N/A
INFECTION PREVENTION AND CONTROL BEST PRACTICES
FULLY
IMPLEMENTED
Body_65262_MedCal:Layout 1
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Long Term Care Infection Prevention Audit
Body_65262_MedCal:Layout 1
2/11/10
8:10 PM
Page 101
Bariatric Assessment
Forms & Tools
Bariatric Assessment : Homecare / Long Term Care Facility
Is your facility ready to accept bariatric patients or residents? Here's a checklist to help you assess your current equipment and
supplies.
Mobility Equipment
Current
Desired
Comments
Current
Desired
Comments
Current
Desired
Comments
Current
Desired
Comments
Current
Desired
Comments
Cane Weight Capacity
Walker Weight Capacity
Walker Width
Wheelchair Weight Capacity
Wheelchair Width
Power Chair Weight Capacity
Power Chair Width
Crutch Weight Capacity
Patient Handling
Transfer Board Weight Capacity
Patient Lift Weight Capacity
Sling Weight Capacity
Transfer Sheet
Stand Assist Lift
Stand Assist Device
Stretcher
Bathroom
Grab Bars
Bath Bench Weight Capacity
Wall Mounted Sink Weight Limit
Toilet Weight Bearing Limit
Toilet Rails/Commode Weight Capacity
Bathtub/Shower Weight Limit
Patient Environment
Patient Seating/Chair Weight Limit
Patient Seating/Chair Width
Patient Seating/Chair Seat Height
Dining Facilities
Dining Chair Weight Capacity
Dining Chair Width
Dining Table Weight Limit
Dining Table Stability
Pathway Around Table Width
Enteral Feeding, Longer Tubes
Continued on page 102
Improving Quality of Care Based on CMS Guidelines 101
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2/11/10
Forms & Tools
8:10 PM
Page 102
Bariatric Assessment
Bariatric Assessment : Homecare / Long Term Care Facility
Sleeping Facilities
Current
Desired
Comments
Current
Desired
Comments
Current
Desired
Comments
Skin Care
Current
Desired
Comments
Patient Apparel
Current
Desired
Comments
Bed Hi-Low Height
Bed Weight Capacity
Bed Sleeping Area Width
Bed Sleeping Area Length
Side Rail Weight Capacity
Bed Scale Weight Capacity
Overbed Table Weight Capacity
Pathway Around Bed Width
Dressing Chair Width
Dressing Chair Weight Cap.
Mattress Weight Capacity
Proper Size/Fit Bedding
Pressure Reducing Mattress
Alternating Pressure Mattress
Entrance, Exit Points
Doorframe Width
Shower Door Width
Hallways/Narrow Passages
Emergency Exit Width
Front Stair/Walkway Width
Monitoring Devices
Large Blood Pressure Cuffs
Scale Weight Limit
CPAP Therapy
Digital Wrist Cuff Monitor
Synchro Pump
Skin Lotions
Powders
Wound Care
Patient Clothing
Towels
Briefs
102
Healthy Skin