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Change of Shift Form  {Error} Original Work Location Select Value {loc_name_Options} I am temporarily Covering for this location ( Select this location if you are covering temporarily for a different unit other than your original work location) Select Temporary Work Location {ListBox1_Options} Document Date Coordinator MEDICATION/CABINET Medication stored in separate bins for each individual Medication bins labeled properly Pills administered initialed on blister pack Liquids and other bulk medications properly labeled DCed/Expired medication removed from individual medication bins New medications and all PRNs accompanied with PMOF Cabinet neat, organized and devoid of items not belonging to it Controlled drugs under double lock Controlled drug count sheet signed and accurate by previous shift staff All missing pills from controlled drug accounted for Medication cabinet neat and well organized First Aid kit with enough supplies and with no item missing CPR Guard, thermometer/other assigned equipments in cabinet Blood pressure machine in working condition Finger-stick machine work; diabetic supply adequate (if applicable) Medical supply fitting for individual needs adequate MEDICATION MARs neat, stapled together with all binder rings intact All physician orders current, signed and dated All medications entered on MARs as seen in PMOFs & approved by RN All medication labels including Rx #s match physician orders and MAR All documentation in accordance with PMOFs & MTTP policies Medication errors/omissions explanations, RN notification documented All pills missing from bubble pack accounted for on MAR PRN/Stat (one time only) medication recorded correctly Medication cabinet locked and key handed over BP, pulse, blood sugar, weight etc documented as indicated (if app.) OTHER Seizure Chart updated (if applicable) Fluid/BM/positioning (if app.)/menstrual (if app.) charts updated Nurse Contact Logs checked for proper notification of RN as needed All verbally reported incidents properly documented/signed by staff Weight recorded for all consumers as indicated Activity schedule and Emergency Contact List current All menus updated to reflect current week Food supply appropriate per menus and adequate for at least 3 days Medical appointments (brown packet) thoroughly reviewed and instructions passed on All monies, receipts and other valuables handed over properly (if app.) All keys, including medication cabinet keys received by incoming staff All individuals accounted for, free of injury/complains, well dressed & well groomed INDIVIDUALS All individual belongings accounted for, have adequate personal need supplies Individuals have adequate seasonal clothing/footwear/linen/towels/hygiene supplies Individual rooms/bathrooms/closets/cabinets/dressers clean and orderly Copy of Current IP/BP (if applicable) with up to date data sheets present Behavioral incidents (if applicable) verbally reported to authority and written report made Evidence of implementation of IP goals and BP (if applicable) present HOME/ENVIRONMENT All areas of ALU/floor/carpet/appliances/cabinets etc. clean, neat and orderly Smoke detectors/carbon monoxide detectors/security systems in working order Fire extinguisher tag current/monthly fire drill done before due date Water thermometer (notify supervisor if temperature > 110o) ALU free of lice wires/holes in walls/broken furniture and other safety hazards Water thermometer/vacuum cleaner/kitchen appliances/washer-dryer working All lights including bedroom lamps working Any/all existing maintenance need reported Cleaning/laundry supplies adequate;cooking utensils in good condtion Over (inside & outside)/stove top clean; kitchen sink free of utensils, dishes All crockery & cutlery in complete sets and all other small items accounted for All furniture intact (tables & chairs with no loose legs) & arranged tastefully Hoyer lift/other common equipments (if applicable) in working condition Enough walk space between furniture and room free of fall hazard All household chores completed for the shift VEHCILES Vehicle parked in assigned location with/club lock on (unless in authorized use) Vehicle policy/registration/first aid kit in the glove compartment Vehicle free of unreported damage including minor scrapes/scratches Vehicle clean & neat and free of stains/spills etc. seat belts working Mileage accurately documented and is comparable with approved activities Vehicle keys/mileage log book taken by incoming staff

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