25-03 Verbal/Telephone Orders Procedure on recording verbal order was updated to reflect current procedure.

Transcription

1 Monthly Hospital-wide Policies and Procedures Review The monthly Laguna Honda policy and procedure review meeting was held on 4/1/2014, 5/7/2014, and a list of revised hospital-wide policies and procedures for JCC approval is summarized below. A copy of the individual revised policies and procedures is included in subsequent pages. New and Procedure Title and Reason(s) for Development Hazard Communication Program Developed to implement and maintain an effective program pursuant to California Occupational Safety and Health Standards, California Code of Regulations, Section Revised Policies and Procedures Title and Reason(s) for Revision Verbal/Telephone Orders Procedure on recording verbal order was updated to reflect current procedure Fire Safety Program New procedural steps on fire precautions for all employees were added Infection Control Manual - F2 Isolation Room Disinfection F F4 Reformatted and minor revisions were made. Infection Control Manual - Handling Resident s Personal Clothing Reformatted, retitled and minor revisions were made. Infection Control Manual - Linen Handling Reformatted and minor revisions were made Injury and Illness Prevention Program (IIPP) This policy is an expansion of the IIPP Summary for implementing and maintaining effective procedures for preventing workplace injury and illness Illicit or Prohibited Drugs or Paraphernalia Possession/Use by Residents or Visitors Appendix A: Contraband Clinical Search Protocol Contraband clinical search protocol was added as an appendix to the policy. Procedure was revised to include reference to the appendix. Deleted and Procedure Title and Reason(s) for Deletion F7 Infection Control Manual Storage and Transport of Contaminated Instruments from Patient Care Areas no longer valid.,,, Pharmacy & Therapeutics Committee,,,,,,,,, * Hospital Executive Committee; Medical Executive Committee; Nursing Executive Committee

2 Departmental Policies and Procedures Review Departmental policy and procedure reviews were conducted in the past months and a list of revised departmental policies and procedures for JCC approval is summarized below. A copy of the individual policies and procedures is included in subsequent pages. Nursing Policies and Procedures New Policies and Procedures F 7.0 Title and Reason(s) for Development Replacement and Care/Maintenance of an Existing Suprapubic Catheter This policy was created specifically for management of suprapubic catheter. This was originally included in NPP 5.0 Nursing Management of Indwelling Catheter (Revised 2006). Revised Policies and Procedures C 4.0 Title and Reason(s) for Revision Physician Notification of Change in Resident Status Appendix A Using SBAR Method of Communication C 5.0 D2 2.0 D5 4.0 Revisions include more detailed steps for nurses before contacting the physician using SBAR. Maintaining Accurate Neighborhood Census Revision in policy includes changing in title "unit" to neighborhood", minor verbiage changes in policy statement, additional policy statements, change in purpose statement, and rearranging formatting definition before procedure section. Bathing Alternatives/Bed Baths Revision in the policy includes minor verbiage changes in policy statement, additional purpose statement to alternative bathing techniques, redefining bathing alternatives. Procedure Section was made clear with sections including preparation to alternative bathing & alternative bathing techniques. Updated references. Arm Sling Revisions include minor verbiage changes in the policy statement and added in the policy that each arm sling should be individually labeled with resident's name. The purpose statement was simplified to the proper use of arm sling. Simplify the procedure section to following rehab staff recommendation or manufacturer's instructions in proper application & use of an arm sling. For Licensed Nurses to document any abnormal findings and non-adherence of resident to treatment in the interdisciplinary progress notes. Updated the references. * Hospital Executive Committee; Medical Executive Committee; Nursing Executive Committee

3 F 5.0 G 6.0 K 10.0 M 4.0 M 6.0 Nursing Management of Urinary Catheters (formerly Nursing Management of Indwelling Catheters) Revision includes title changed from "indwelling" to "urinary" catheters with major changes in policy statement. Statement regarding Suprapubic Catheter was removed since a separate NPP was created specifically for management of suprapubic catheter. Purpose statement was simplified to minimizing risk for CAUTI. Procedure section has 4 sub-headings: equipment, preparation of inserting intermittent and indwelling urinary catheter, proper techniques for urinary catheter maintenance, and documentation. Updated references. Two new appendices were created: Appendix 1 Procedures in Inserting Urinary Catheters for Male and Female Resident Appendix 2 - Application of Urinary Leg Bag (adapted from NPP F 4.1 Care for Urinary Leg Bag) Behavioral Risk Assessment and Guideline for Care Planning Revisions include verbiage change in policy statement such as assessment is done upon admission, quarterly, and whenever there is a change in condition. In the procedure section, accessing of online care plan template. Prevention and treatment of Skin Tears (formerly known as Minor Skin Tear) Revisions include change in title statement which included the prevention and treatment of skin tears, verbiage changes in policy and purpose statements. Under the procedure section, sub-headings were renamed and were simplified into 3 sections namely: prevention of skin tear, treatment of skin tear, and documentation. Added reference. Protocol for Personal Laundry and Use of Washer & Dryer Machine Revisions include the title change from "guidelines" to "protocol" and added use of washer & dryer machine. Additional protocol statement regarding operating of washing machine. Created an appendix for quick reference for operating washing machine & dryer. Transport Gurney Protocol performance appraisal, using of appropriate gurney based on resident weight, and cleaning of gurney after use and reporting to facility services if gurney needs repair. Adding appendix for quick reference on operating transport gurney. M 7.0 Electric Medical/Surgical Bed Protocol * Hospital Executive Committee; Medical Executive Committee; Nursing Executive Committee

4 M 8.0 M 11.0 performance appraisal, safety procedure before cleaning the electric bed, reporting to facility services if electric bed needs repair, and proper use of special features of the electric bed such as using bed to weight resident, use of bed-exit alarm, and accessing CPR-mode of the bed. Adding appendix for quick reference on operating electric medical/surgical bed. Electronic Wheelchair Scale Protocol performance appraisal, safety procedure & steps in using the scale in standing position & when in wheelchair, storing and maintenance of wheelchair scale. Adding appendix for quick reference on operating wheelchair scale. Warming Cabinet Protocol performance appraisal, safety procedures in operating warming cabinet such as setting the temperature within the acceptable temperature of warming cabinet, reporting to facility services for malfunctioning warming cabinet, and cleaning of warming cabinet. Adding appendix for quick reference on operating warming cabinet. Deleted and Procedure F 4.1 Title and Reason(s) for Deletion Care for Urinary Leg Bag This P&P was made as an appendix to the revised NPP F 5.0 Nursing Management of Urinary Catheters. * Hospital Executive Committee; Medical Executive Committee; Nursing Executive Committee

5 Facility Services and Procedure Revised and Procedure EM-8 Title and Reason(s) for Revision Domestic Washers and Dryers Repair and Maintenance Revisions included changes in the title, policy of reporting problems, procedure for changing condensers in dryers and procedures for repairing and replacement. * Hospital Executive Committee; Medical Executive Committee; Nursing Executive Committee