Medication Cart / Treatment Cart Page 1 of 3 (Cart)

Medication Cart / Treatment Cart Page 1 of 3 (Cart) Objective: To demonstrate that storage of medications meets legal and facility standards. MEDICATION/TREATMENT CART 1. The medication/treatment cart is locked or kept in a locked room. 129.1.a.ii 2. Cart is clean and well organized. surface wiped clean after each medication pass bins cleaned regularly and when resident is discharged cart is cleaned following any outbreak 3-5 3. Discontinued or expired medications have been removed (regular/narcotic/prns/ treatments and stock). 4. No unlabelled medication samples. 136.2.i 5-5 122.1.b MSSA 68 5. All medications are kept in the original labeled container. 126 6. All drugs with illegible labels are removed for disposal 136.1.b 7. No family supplied medications 122.1.b 8. No handwritten changes to directions on label or card (except by physician or pharmacist). 4-9 9. External and internal medications are stored separately. 3-3 10. Medications are dated when opened and replaced when expired: Eyedrops.3 months or as labeled Miacalcin....4 weeks Nitrostat..12 months Inhalation solutions..28 days ipratropium, salbutamol) Sterile water / Sodium Chloride for irrigation 7 days Gravol multidose Morphine multidose B12 Modecate Xylocaine hotrexate 129.1.a.iv 5-2 11. Eye drops are labeled with individual resident s name, (eg. Isopto Tears)

Medication Cart / Treatment Cart Page 2 of 3 (Cart) Objective: To demonstrate that storage of medications meets legal and facility standards. 12. Creams, ointments, etc. supplied in a bulk container are not used for more than one resident. (Infection control practices) 13. Unused portions of medicated and sterile dressings are discarded as per manufacturer direction. 129.1.a.iv 14. Inhalers are capped and aerochambers are stored hygienically and cleaned weekly. (Infection control practices) 15. Back-up keys can be accessed if needed. stored in 3-4 16. Separate reorder labels are stored in a systematic manner & current. 4-11 NARCOTIC AND CONTROLLED MEDICATIONS 17. All Narcotic and Controlled substances are kept under double lock until destruction. 129.1.b 18. Only Narcotic and Controlled substances are stored in Narcotic & Controlled med bin. 129.1.b 19. N & C Count Records are accurate. wasted narcotics are double signed 129.1.b 6-6 20. Narcotic / Controlled Shift Count completed by 2 nurses each shift change. discontinued medication will continue to be counted until removed 6-7 21. Monthly audit of shift count sheets is completed to identify discrepancies. 130.3 MULTIDOSE CARDS OR STRIPS 22. Resident sections are clearly labeled (bins or divider cards). 12-4 3-4 23. Discontinued drugs are correctly identified on all packets in current multidose strip. 12-11 24. Vials are current and orders not duplicated in the strip/multi-dose card. 12-9

Medication Cart / Treatment Cart Page 3 of 3 (Cart) Objective: To demonstrate that storage of medications meets legal and facility standards. 25. Time changes are addressed safely on all multi-dose packaging. 12-10 26. Standard HOA s are used except when specifically requested otherwise. 12-6 Other:

Medication Storage Page 1 of 2 (Storage) Objective: To demonstrate that storage of medications meets legal & facility standards. MEDICATION ROOM / NURSE S STATION 1. Locked or cupboards locked. 130.1 2. No hazardous chemicals or cleaning compounds stored in medication rooms. MSSA 74 3. Lighting is adequate to clearly read labels. MSSA 80 4. Medical Pharmacy s phone, fax, pager & Consultant Pharmacist number posted & current. 118.2 5. Poison control centre contact information is available (see pharmacy contact numbers form). 118.3 6. References available Medical Pharmacy P & P Manual CPS or e-cps ODB formulary or e-formulary 118.1 MSSA 17 STOCK MEDICATIONS 7. No more than a 3-month supply of drugs for a resident 124 8. Internal medications are separated from external. 3-3 9. No expired medications. 136.2.1 10. No items requiring refrigeration stored at room temperature. 129.1.a.iv REFRIGERATOR 11. Refrigerator is in locked room or medication box is locked. 130.1 12. Vaccines are stored away from the door. temperature of vaccine fridge is monitored and recorded daily (Public Health recommendations) 13. All discontinued and expired medications and vaccines have been removed. 136.2.1 14. Insulin vials, vaccines and Tuberculin PPD are dated when opened & discarded after 30 days or as recommended by manufacturer. 129.1.a.iv

Medication Storage Page 2 of 2 (Storage) Objective: To demonstrate that storage of medications meets legal & facility standards. 15. Thermometer available in any fridge used for medication storage. refrigerator temperature is between 2º- 8ºC (36º F - 46ºF) 129.1.a.iii 129.1.a.iv 16. Refrigerator is used solely for the storage of medications and vaccines. 129.1.a.i MSSA 85 EMERGENCY STARTER BOX 17. Procedures for use are followed correctly. re-ordered from pharmacy in ESB DRB signed in on the ESB DRB 123.b 2-4 18. Only and all medications are present as per facility s Master List. list updated annually, last review stock monitored regularly on ESB monitoring form 123.c 19. No outdated medications. 136.2.1 20. Box is stored in a locked room or cupboard 130.1 21. Narcotic and Controlled Substances are stored under double lock counted at shift change by 2 nurses 129.1.b 6-7 22. Appropriate clinical information is available (e.g. warfarin DI, morphine dose calc chart, etc.) MSSA 17 MSSA 19

Insulin Delivery and Monitoring Page 1 of 2 (Ins) Objective: To demonstrate that storage of Insulin, Glucose Monitoring Device and Lancing devices meet standards for safe use. INSULIN 1. Pen (barrel) is labeled with resident s name. 2. Current cartridge/vial on cart has been dated when opened. all insulin dated less than 1 month 129.1.a.iv 5-1 3. Needle tips have been removed from pen safety needle tips in use (Occupational Health & Safety Act, Needle Safety Regulation (O. Reg. 474/07) ) 4. Product for hypoglycemic rescue on hand. Glucagon 15g carbohydrate (CDA clinical practice guidelines of Hypoglycemia 2008) 5. MAR documentation indicates injection site and time. 6. Insulin cartridge in pen matches insulin type on MAR. (CNO practice standard medications revised 2008) 7. Current insulin vials and pen are stored at room temp. 8. The types of insulin pens are limited. Instruction available for pens in use 129.1.a.iv MSSA 78 BLOOD GLUCOSE METERS 9. Only one box of strips open per meter. If multiple boxes, ordered and used in organized manner. strip canisters are dated when opened 5-2 To be completed annually

Insulin Delivery and Monitoring Page 2 of 2 (Ins) Objective: To demonstrate that storage of Insulin, Glucose Monitoring Device and Lancing devices meet standards for safe use. 10. er is cleaned with an appropriate cleaning compound e.g. accelerated hydrogen peroxide (In accordance with Public Health policy) 11. er accuracy checked with control solution or with lab comparison within past month/week according to manufacturer recommendation. (In accordance with Manufacturers Recommendations) 12. Control solution dated when opened and discarded after 6 months. (In accordance with Manufacturers Recommendations) 13. Blood glucose readings are systematically recorded. (CNO Nursing practice standards documentation revised 2008) 14. ers for individual resident use are labeled with resident s name. (CDC handout recommended infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens) LANCING DEVICES 15. Lancing device assures no cross contamination among residents: individual device used per resident disposable lancets used institutional use approved device used (CDC handout recommended infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens; Health Canada Advisory March 24, 2009) To be completed annually

Documentation and Administration Page 1 of 2 (Doc) Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. MAR SHEETS 1. Master Signature list is current. (CNO Communication p 6 h) 8-1 2. All medications are signed for on MAR and codes used appropriately. 131.2 8-1 3. New orders include drug name, strength, directions for use, HOA, route and date of order. MAR signature boxes are blocked off appropriately. 8-3 4. Change of orders is correctly documented. old order discontinued new order written 8-3 5. Discontinued orders are clearly documented. 6. If a range dose, quantity given is documented. (CNO) 8-3 7. MARS signed and dated as being checked as per facility policy. 8-2 8. MARS are blocked off correctly for q2d, MWF, etc. orders. 8-3 9. Drug Interaction Alert notice communicated with MD and placed with MAR. 9-3 10. MAR book is kept in a secure, private location when not in use, or emar screen closed. (CNO Security P.8 b) 11. e-mar orders indicate correct source of medication. (MP Med-e-Link procedure guide for PCC) 12. Self administered medications have an order to allow self administration medications are stored securely 131.6 5-5 PRN DOCUMENTATION 13. PRN orders include: frequency indications for use 8-4

Documentation and Administration Page 2 of 2 (Doc) Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. 14. Documentation of administration is noted on MAR s +/or, back of MAR, PRN sheet or progress notes. flagging system in place to remind nurse to follow-up 8-4 15. Documentation includes: reason for use effect of dose given 8-4 TREATMENT SHEETS 16. Order includes: frequency area to be treated 8-1-1 17. All treatments are signed for or codes used appropriately. 8-1-1 18. New orders include drug name, strength, directions for use, HOA, and date of order. TAR signature boxes are blocked off appropriately. 8-1-1 19. Change of orders is correctly documented. old order discontinued new order written 8-1-1 20. Discontinued orders are clearly documented. 8-1-1 21. Observations are noted at least every 7 days by a nurse. 8-1-1 22. TARS are signed and dated as being checked as per facility policy. 23. Self administered treatments have an order to allow self administration treatments are stored securely 8-2 131.6 5-5 Other:

Drug Record Book Page 1 of 1 (DRB) Objective: To demonstrate that proper procedures for documenting of ordering and receiving of medications meets legal and facility standards. DRUG RECORD BOOK (Non Multi-Dose Meds) 1. All medications ordered are identified by signature/initials and dated. new orders refill orders 133 4-1 2. All medications received are identified by signature/initials and dated. 133 4-1 3. Drug Record Book page indicates which orders have been faxed to pharmacy. 133 4-1 4. Drug Record Book pages are used in sequence and unused boxes are crossed off. 133 4-1 5. All Drug Record Book sheets are kept for 2 years. 133 4-1 6. Quantity and Rx # received is recorded for all new orders (circled on reorders). 133 4-1 7. Medication Starter Packs are reordered correctly with original order and starter pack re-order label. (may be in separate ESB DRB) 133 4-1 8. BPMH Reconciliation / Admission orders Drug Record Book Page indicates: drugs ordered drugs not to be sent drugs received with date, qty & Rx # 133 4-3 9. Bulk ordering system follows policy eg. lactulose, soflax, BG strips. 10-7 10. Pharmacy Nursing Communication sheets are filed in the DRB and addressed in a timely manner. 4-10 11. All other pharmacy forms are filed appropriately (ie. Drug Interaction Alert in Narcotic and Controlled med count binder on cart). 9-3 4-13 4-14 DOCUMENTATION OF RECEIVING MULTI-DOSE CARDS OR STRIPS 12. Shipping Report is checked against each resident s name, signed and dated. 13. Shipping Reports are filed in chronological order and kept for 2 year 133 12-9 133 12-9

Resident Safety Audit Page 1 of 4 (RSA) Objective: To demonstrate that proper procedures for documentation, transportation and availability of medications meet legal and facility standards. Resident Charts Reviewed PHYSICIAN S ORDERS 1. All orders: are legible and clear no missing info, eg. doses, frequency, strength, route, indication (CNO Assessment P.4) 2D MSSA 31 MSSA 32 2. No inappropriate abbreviations used OD, QD, OU, OS cc U or u, IU ss or SS HS other 3-9 MSSA 33 3. No trailing zeros after decimal points or naked decimal points. eg. 1.0 mg use 1 mg.5 mg use 0.5 mg 3-9 MSSA 33 4. All information complete at top of each physician order sheet: resident first & last name facility name allergies, room / unit 4-2 5. All orders are signed or cosigned by physician: written orders are signed and dated telephone orders are signed and dated by the nurse and cosigned by the physician within 7 days. 4-2 MSSA 38 6. A medical directive is in place to authorize Physician Assistant to sign orders. Physician and Physician Assistant s names clearly stated on Medical Directive A copy of the Medical Directive is located: in the dispensary in in the home in accessible to staff at any time

Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. Resident Safety Audit Page 2 of 4 (RSA) Resident Charts Reviewed 7. Orders are faxed or sent via digital pen. 8. Admission or re-admission orders include the prescribing physician s name. 4-2 4-3 9. Order sheets of residents with same or similar names are differentiated. MSSA 11 MEDICATION REVIEW FORMS 10. Nurse prechecks and dates as per facility policy. 8-5 11. Unused lines have been crossed off after physician has signed. 8-5 12. Copy has been sent to pharmacy. 13. After Medication Review signed, a new Physician s Order Sheet is started and previous blank spaces crossed off. 8-5 8-5 14. Physician s orders and Medication Reviews in chart are together in chronological order. 8-5 15. Medication Review has been completed within the past quarter (or as per policy for Retirement Home residents). 134.c 8-5 16. CrCl has been calculated within past 12 months and printed on medication review. MSSA 15 MAR/TARS 17. All orders are: accurately transcribed from Physician s orders no inappropriate abbreviations orders are transcribed to MAR or TAR according to facility policy. 18. Crushing: only suitable medications are identified to be crushed residents requiring crushed medications are identified 19. Allergies noted 8-3 3-9 8-1-1 5-3 8-2

Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. Resident Safety Audit Page 3 of 4 (RSA) Resident Charts Reviewed MEDICATIONS 20. All ordered medications are available in appropriate quantities. 124 21. No discontinued or expired medications on hand. 22. All medications properly labeled and stored. 136.1.a 136.1.d.i 5-4 129.1.a.iii MSSA 48 23. Cytotoxic medications are packaged separately and appropriately labeled injectable and topical cytotoxics are stored in a resealable plastic bag 5-6 MEDICATION RECONCILIATION 24. Best Possible Medication History (BPMH) information includes: allergies drug, dose, frequency, route info from two sources all orders from all sources included in BPMH new, continue box checked and discontinue box X d out code indicated for discontinued order and order clearly crossed out list recorded by, telephone order taken by completed 10-8 MEDICAL DIRECTIVES 25. Medical directives are written out in full on the MAR when used order is clearly identified as a medical directive 8-3 26. Medical directive exceptions and allergies are clearly noted on order sheet, MARS, TARS and QMR. 27. Each medical directive individually authorized by the physician on order sheet. 117 117 28. Medical directives used only for appropriate indication. 117

Objective: To demonstrate that proper procedures for documentation and administration of medications meet legal and facility standards. Resident Safety Audit Page 4 of 4 (RSA) RESIDENT

Medication Pass Page 1 of 2 (MP) Objective: To ensure that safe procedures and correct techniques are followed. To promote efficiency on giving out medications. To assist the professional team in optimizing treatment outcomes. AUDITED BY: Clinical Consultant Pharmacist PASS TIME: NURSE/UCP DOING PASS: DATE: MEDICATION PASS 1. Drug cart is kept in line of sight or locked at all times. 129.1.a.ii 2. emar screen is locked when nurse is away from cart OR patient information protected when MAR book not attended by nurse (CNO P.8 B) 3. No drugs outside the cart during med pass. 129.1.a.ii 4. A flagging system is used to ensure no residents are missed. 3-6 12-5 5. Minimal interruption during the med pass. 6. All medications and supplies are available on cart. 3-6 7. Lighting is adequate to clearly read MARS and labels. MSSA 80 ORAL MEDICATIONS 8. Nurse checks each medication systematically against the MAR sheet. 3-6 9. MAR Sheet is signed at the time the medication is given (no prepour). 3-6 10. Pills are not touched by hand. 11. Oral liquids poured at eye level. 12. Suspensions are shaken before pouring. 13. Medications only crushed when noted on MAR sheet. 5-3 14. Resident positioned properly, ie. not lying down or about to. 15. Medications are not left at table or in resident s room unless there is a physician s order. 5-5 16. All medications are given correctly in relation to meals (ac/with food). 131.2 To be completed at the request of the facility or at the discretion of the Clinical Consultant Pharmacist

Medication Pass Page 2 of 2 (MP) Objective: To ensure that safe procedures and correct techniques are followed. To promote efficient use of nursing time spent on giving out medications. To assist the professional team in optimizing treatment outcomes. AUDITED BY: Clinical Consultant Pharmacist DISCUSSED WITH: PASS TIME: NURSE/UCP DOING PASS: DATE: NON-ORAL MEDICATIONS 17. Proper procedures are used for the administration of: ophthalmics otics inhalers & aerochambers nasal preparations patches insulin 18. Resident dignity is respected. 19. Proper sanitation used and hand hygiene. INSULINS 20. Swab top of insulin cartridge or vial before applying needle. 21. Air is expelled before each injection with the 2 unit test. 22. Suspensions are rolled correctly. 23. Insulin is given at correct time in relation to when resident eats. 24. Needles and lancets are disposed of safely: no recapping of needles safety needles in use discarded in sharps container To be completed at the request of the facility or at the discretion of the Clinical Consultant Pharmacist

Medications for Disposal Page 1 of 2 (MD) Objective: To ensure that all medications are administered as ordered. To ensure accountability for all medications through the disposal process. To identify discrepancies with charting of medications. DISCUSSED WITH: DISCONTINUED MEDICATIONS 1. Are removed from cart same day 2. All Narcotics & Controlled medications are maintained under double lock until disposal (may use a N&C mailbox) the Drug Destruction and Disposal record is complete, double initialed and kept with meds until disposal (use binder) continue to count until they are removed from the cart into a N&C mailbox or separate double locked secure one way storage 3. Used medication patches are discarded appropriately. in medication disposal 136 5-4 129.b 6-5 6-5 STRIP PACKS 4. All strip packs for disposal have either a code for withholding medication code same as MAR code a direction change sticker and/or affected order circled MAR reflects direction change tablet identified on pouch matches discontinued order 12-5 5. Pharmacy has been notified of discharge of residents (identified by presence of full strip packs) 12-10 6. Codes for withholding medications used appropriately code 7 (sleeping) not used for essential medications code 3 (away from home without medications) is not used if LOA medications could have been sent with the resident. 121 7-5 To be completed annually

Medications for Disposal Page 2 of 2 (MD) Objective: To ensure that all medications are administered as ordered. To ensure accountability for all medications through the disposal process. To identify discrepancies with charting of medications. DISCUSSED WITH: VIALS 8. No medications remaining in vials containing short term medications. if tablets remain, MAR indicates medication has been appropriately held or discontinued Emergency Starter Box meds, if used, were ordered and pharmacy notified. 131.2 2-4 DISCREPANCIES (attach packets if applicable) To be completed annually

Med-e-Pen Audit Page 1 of 2 (Med-e-Pen) Objective: To demonstrate that Med-e-Pen is functioning effectively and is used properly to transmit physician orders to pharmacy Med-e-Pen Hardware: 1. Med-e-Pen is fully charged or charging. 2. Med-e-Pen is positioned correctly in cradle at all times while not in active use. 3. Med-e-Pen cradle is attached to computer and is physically accessible to registered staff and physicians. 4. Med-e-Pen cap is present/available. Med-e-Pen Software and Connectivity: 5. When Med-e-Pen is docked during audit, computer screen shows nothing to download. 6. Internet access is active on computer. 7. Registered staff is able to log into computer (windows application). 8. Med-e-Pen software icons are visible on computer screen. 9. Writing and sending a test order via Med-e- Pen is successful. 10. Viewer is accessible (using unit login/password). (Record IP address and provide to Medical Pharmacies if not). 11. Registered staff is aware of how to access viewer and routinely does so each time orders are sent via Med-e-Pen (or at end of shift at minimum). 12. Physician orders in viewer display same information as is visible on physician order sheets in charts.

Med-e-Pen Audit Page 2 of 2 (Med-e-Pen) Objective: To demonstrate that Med-e-Pen is functioning effectively and is used properly to transmit physician orders to pharmacy Charts: 13. All physicians order sheets in chart contain complete header information written with digital pen. 14. Digital pen is always used on digital paper (no evidence of different pen ink etc.). Registered Staff knowledge of Med-e-Pen: 15. Registered staff on duty is aware of location of: Ink refills Spare digital pen for emergencies Physicians order sheets Med-e-Pen instructions 16. Registered staff demonstrates knowledge of how to confirm that an order has been sent via Med-e-Pen (via confirmation message and viewer access). 17. Registered staff knows procedure of sending orders to pharmacy in case of pen transmission failure (photocopy digital paper or print from viewer, fax to pharmacy). Other:

Facility: Date Audited Unit Type of Audit Completed Cart Storage Ins Doc DRB RSA ICA MP MD MedePen es