| Loc Name |
{loc_name} |
| Doc Date |
{doc_date} |
| Coordinator |
{coordinator} |
| Medication stored in separate bins for each individual |
{medc1} |
| Medication bins labeled properly |
{medc2} |
| Pills administered initialed on blister pack |
{medc3} |
| Liquids and other bulk medications properly labeled |
{medc4} |
| DCed/Expired medication removed from individual medication bins |
{medc5} |
| New medications and all PRNs accompanied with PMOF |
{medc6} |
| Cabinet neat, organized and devoid of items not belonging to it |
{medc7} |
| Controlled drugs under double lock |
{medc8} |
| Controlled drug count sheet signed and accurate by previous shift staff |
{medc9} |
| All missing pills from controlled drug accounted for |
{medc10} |
| Medication cabinet neat and well organized |
{medc11} |
| First Aid kit with enough supplies and with no item missing |
{medc12} |
| CPR Guard, thermometer/other assigned equipments in cabinet |
{medc13} |
| Blood pressure machine in working condition |
{medc14} |
| Finger-stick machine work; diabetic supply adequate (if applicable) |
{medc15} |
| Medical supply fitting for individual needs adequate |
{medc16} |
| MARs neat, stapled together with all binder rings intact |
{medi1} |
| All physician orders current, signed and dated |
{medi2} |
| All medications entered on MARs as seen in PMOFs & approved by RN |
{medi3} |
| All medication labels including Rx #s match physician orders and MAR |
{medi4} |
| All documentation in accordance with PMOFs & MTTP policies |
{medi5} |
| Medication errors/omissions explanations, RN notification documented |
{medi6} |
| All pills missing from bubble pack accounted for on MAR |
{medi7} |
| PRN/Stat (one time only) medication recorded correctly |
{medi8} |
| Medication cabinet locked and key handed over |
{medi9} |
| BP, pulse, blood sugar, weight etc documented as indicated (if app.) |
{medi10} |
| Seizure Chart updated (if applicable) |
{othe1} |
| Fluid/BM/positioning (if app.)/menstrual (if app.) charts updated |
{othe2} |
| Nurse Contact Logs checked for proper notification of RN as needed |
{othe3} |
| All verbally reported incidents properly documented/signed by staff |
{othe4} |
| Weight recorded for all consumers as indicated |
{othe5} |
| Activity schedule and Emergency Contact List current |
{othe6} |
| All menus updated to reflect current week |
{othe7} |
| Food supply appropriate per menus and adequate for at least 3 days |
{othe8} |
| Medical appointments (brown packet) thoroughly reviewed and instructions passed on |
{othe9} |
| All monies, receipts and other valuables handed over properly (if app.) |
{othe10} |
| All keys, including medication cabinet keys received by incoming staff |
{othe11} |
| All individuals accounted for, free of injury/complains, well dressed & well groomed |
{indi1} |
| All individual belongings accounted for, have adequate personal need supplies |
{indi2} |
| Individuals have adequate seasonal clothing/footwear/linen/towels/hygiene supplies |
{indi3} |
| Individual rooms/bathrooms/closets/cabinets/dressers clean and orderly |
{indi4} |
| Copy of Current IP/BP (if applicable) with up to date data sheets present |
{indi5} |
| Behavioral incidents (if applicable) verbally reported to authority and written report made |
{indi6} |
| Evidence of implementation of IP goals and BP (if applicable) present |
{indi7} |
| All areas of ALU/floor/carpet/appliances/cabinets etc. clean, neat and orderly |
{home1} |
| Smoke detectors/carbon monoxide detectors/security systems in working order |
{home2} |
| Fire extinguisher tag current/monthly fire drill done before due date |
{home3} |
| Water thermometer (notify supervisor if temperature > 110o) |
{home4} |
| ALU free of lice wires/holes in walls/broken furniture and other safety hazards |
{home5} |
| Water thermometer/vacuum cleaner/kitchen appliances/washer-dryer working |
{home6} |
| All lights including bedroom lamps working |
{home7} |
| Any/all existing maintenance need reported |
{home8} |
| Cleaning/laundry supplies adequate;cooking utensils in good condtion |
{home9} |
| All crockery & cutlery in complete sets and all other small items accounted for |
{home11} |
| All furniture intact (tables & chairs with no loose legs) & arranged tastefully |
{home12} |
| Hoyer lift/other common equipments (if applicable) in working condition |
{home13} |
| Enough walk space between furniture and room free of fall hazard |
{home14} |
| All household chores completed for the shift |
{home15} |
| Vehicle parked in assigned location with/club lock on (unless in authorized use) |
{vehi1} |
| Vehicle policy/registration/first aid kit in the glove compartment |
{vehi2} |
| Vehicle free of unreported damage including minor scrapes/scratches |
{vehi3} |
| Vehicle clean & neat and free of stains/spills etc. seat belts working |
{vehi4} |
| Mileage accurately documented and is comparable with approved activities |
{vehi5} |
| Vehicle keys/mileage log book taken by incoming staff |
{vehi6} |
| No records |
|
MEDICATION/CABINET