Accreditation Readiness Audit

Information

Logs

Code cart completed month to date
Warmer logs are completed daily (IV warmers, blanket warmers)
Fridge logs are completed month to date (food, meds, specimens) - assure values are in range

Meds (including biologicals) secured secured: carts, cabinets, rooms and drawers.
All multi dose vials are labeled (opened have initials and and exp dare written on label)
All sharps are secured.

Fire extinguishers, shut off valves, egress, fire alarm pull stations not blocked.
Doors not propped and latch properly. Check for combos written on door frames.
Locks functioning properly
Ceiling tile integrity
Staff able to demonstrate how to pull info on chemicals (hint: MSDS on KaleidaScope)
Chemicals labeled and stored properly / secured.
O2 tanks secured / max amt of "E" tanks of 12 in areas.
Storage - nothing on floor and nothing 18" from ceiling
Hallways clear / no storage of equipment (plugged in items become "storage")

Food and drink not in patient care areas / with clean supplies / charts.
Linen carts are covered and no supplies on top of carts / no build up of old tape.
No stains on upholstery, curtains, etc.
Proper use of PPE and hand hygiene / check isolation rooms for dedicated equipment and proper PPE and hand hygiene according to isolation type
No outside corrugated cardboard.
Appropriate use of clean and dirty storage (no vacuum cleaners in clean equipment rooms, etc.).
No dust buildup on equipment (scales, EKG, VS machines, etc.).
Equipment cleaned between patients (thermometers, BP cuffs, IV poles, glucose terms)
Proper scope cleaning process, solution and test strips not expired.
Dialysis mobile carts free from chemical build up
No pre-opened supply packaging - check ET tubes and stylettes (check airway boxes).
Nourishment rooms are clean (microwaves, fridges, freezers, ice machines).
High areas clean from dust (check vents).
Furniture integrity: No torn mattresses / stretcher pads, chairs, pads, wheelchairs, couches, etc.

Care plans (CPs) updated daily, addressing co-morbidities, staff know how to utilize MPage
Nursing assessment done within 24 hours of admission (CPs included).
Meds given in appropriate timeframe (critical: 30 min +\- for total of 60 min window, non-critical 60 min +\- for total of 120 min window).
Restraints: initiation and order mode matches, order within 60 min of initiation, timely assessments, staff can speak to removing restraints as soon as safe for pt.
Advance directive: pt have an advance directive? If no , do they want assistance or is follow up to obtain one documented?
Blood transfusion pts: documentation of VS monitoring per policy.
Pain reassessed per policy.
PostOp / procedure pts: pre proc notes in eMR, Nursing Op record (serves as post op note) verbally signed by proceduralist.
H&P updated (within 30 days of admission, prior to procedure).
Consents complete and legible.
General anesthesia pts: Pre-anesthesia eval complete.

Confidentiality: no visible HPI.
Document control: no uncontrolled documents (printed policies, no extra copies of printed forms, posted items without dates). Staff can speak to process for obtaining Kaleida Health forms and documents.
Equipment that is broken has been tagged appropriately and is not in service.
Food in pt fridges are labeled and dated.