Stillwater Center Tube Feeding Room Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Management and Training

• Are staff trained in the preparation of enteral tube feeding?

  Yes

  No

  N/A

Storage

• Is the feed stored according to the manufacturer’s instructions?

  Yes

  No

  N/A

• Is the feed within its expiry date?

  Yes

  No

  N/A

• Is single-use equipment, such as mesuring tools, stored in a clean, lidded container?

  Yes

  No

  N/A

Equipment Management

• Are single-use items disposed of after use?

  Yes

  No

  N/A

• Does staff use the correct feeding bags?

  Yes

  No

  N/A

• During the initial brief tour, are Tube Feeds stored and/or prepared under sanitary conditions?

  Yes

  No

  N/A

• During the initial brief tour, does the facility handle, prepare, and distribute Tube Feeds in a manner that prevents foodborne illness to the residents?

  Yes

  No

  N/A

• Is the food stored at the appropriate temperatures?

  Yes

  No

  N/A

• During follow-up visits to the kitchen, are the Formula Supplies stored under sanitary conditions?

  Yes

  No

  N/A

• Does the facility provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and dietary needs, taking into consideration the preferences of each resident?

  Yes

  No

  N/A

• Does the facility provide food prepared by methods that conserve nutritive value, flavor, and appearance and provide food and drink that is palatable, attractive, and at a safe and appetizing temperature?

  Yes

  No

  N/A

• Is food prepared in a form that meets the individual needs of the residents?

  Yes

  No

  N/A

• Was food procured from approved or satisfactory sources and was food stored, prepared, distributed, and served in accordance with professional standards for food service safety?

  Yes

  No

  N/A

• Were dishes and utensils cleaned and stored under sanitary conditions?

  Yes

  No

  N/A

• Is the Tube Feed preparation equipment clean?

  Yes

  No

  N/A

• Does the facility follow the physicians order for preparation of Tube Feeds, and does the order meet the nutritional needs of the residents?

  Yes

  No

  N/A

• Does the facility have a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications in the timeframe allowed?

  Yes

  No

  N/A

• Does the facility have a sufficient number of competent staff to safely and effectively carry out the functions of the food and nutrition services?

  Yes

  No

  N/A

• Do Formula technicians have Serve Safe Manager Level 2 certification?

  Yes

  No

  N/A

• During mixing, does a staff member utilize a scale?

  Yes

  No

  N/A

• Documentation regarding temperature checks and ml's count filled by staff in acordance with requirement?

  Yes

  No

  N/A