2017 hospital national patient safety goals - baptist health ......2016/12/13 · the goal focus on...
TRANSCRIPT
The purpose of the NPSGrsquos are to improve patient safety and outcomes The goal focus on problems in health care safety and how to solve them
2017 Hospital National Patient Safety Goals
Personal Investment in Orientation
Be an active participant in your orientation Ask Questions- get all the information you need Orientationcompetency assessment involvesCritical thinking skillsEffective communication strategies Safe skill performance as reflected in training planWork with your preceptor to complete the orientation
plan documentation It is a tool for both of you
Keeping Your Patients Safe
You and your preceptor are a TEAM
Orientees ndash Nursing Interventions are based on the approved plan of care per your preceptor
Orientees ndash Report any changes in patients condition immediately to the preceptor The preceptor guides the responseinterventions to those changes
The preceptor and orientee should use the ldquoRepeat-Backrdquo process in communicating key information or instructions
NPSG 1 Improve the accuracy of patient identification
NPSG010101 Use the two patient identifiers whenever providing care whether medication treatment surgery or even meals Patientrsquos Name Patientrsquos Account Number (FIN)
NPSG010301 Eliminate transfusion errors related to patient misidentification
Patient Identifiers on Lab Specimens All specimens must be properly labeled before
leaving the patientrsquos bedside
Unlabeled specimens cannot be left with patient to be labeled later
Pull up the Order in Cerner and print label at bedside while collecting specimens
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Personal Investment in Orientation
Be an active participant in your orientation Ask Questions- get all the information you need Orientationcompetency assessment involvesCritical thinking skillsEffective communication strategies Safe skill performance as reflected in training planWork with your preceptor to complete the orientation
plan documentation It is a tool for both of you
Keeping Your Patients Safe
You and your preceptor are a TEAM
Orientees ndash Nursing Interventions are based on the approved plan of care per your preceptor
Orientees ndash Report any changes in patients condition immediately to the preceptor The preceptor guides the responseinterventions to those changes
The preceptor and orientee should use the ldquoRepeat-Backrdquo process in communicating key information or instructions
NPSG 1 Improve the accuracy of patient identification
NPSG010101 Use the two patient identifiers whenever providing care whether medication treatment surgery or even meals Patientrsquos Name Patientrsquos Account Number (FIN)
NPSG010301 Eliminate transfusion errors related to patient misidentification
Patient Identifiers on Lab Specimens All specimens must be properly labeled before
leaving the patientrsquos bedside
Unlabeled specimens cannot be left with patient to be labeled later
Pull up the Order in Cerner and print label at bedside while collecting specimens
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Keeping Your Patients Safe
You and your preceptor are a TEAM
Orientees ndash Nursing Interventions are based on the approved plan of care per your preceptor
Orientees ndash Report any changes in patients condition immediately to the preceptor The preceptor guides the responseinterventions to those changes
The preceptor and orientee should use the ldquoRepeat-Backrdquo process in communicating key information or instructions
NPSG 1 Improve the accuracy of patient identification
NPSG010101 Use the two patient identifiers whenever providing care whether medication treatment surgery or even meals Patientrsquos Name Patientrsquos Account Number (FIN)
NPSG010301 Eliminate transfusion errors related to patient misidentification
Patient Identifiers on Lab Specimens All specimens must be properly labeled before
leaving the patientrsquos bedside
Unlabeled specimens cannot be left with patient to be labeled later
Pull up the Order in Cerner and print label at bedside while collecting specimens
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NPSG 1 Improve the accuracy of patient identification
NPSG010101 Use the two patient identifiers whenever providing care whether medication treatment surgery or even meals Patientrsquos Name Patientrsquos Account Number (FIN)
NPSG010301 Eliminate transfusion errors related to patient misidentification
Patient Identifiers on Lab Specimens All specimens must be properly labeled before
leaving the patientrsquos bedside
Unlabeled specimens cannot be left with patient to be labeled later
Pull up the Order in Cerner and print label at bedside while collecting specimens
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Patient Identifiers on Lab Specimens All specimens must be properly labeled before
leaving the patientrsquos bedside
Unlabeled specimens cannot be left with patient to be labeled later
Pull up the Order in Cerner and print label at bedside while collecting specimens
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Defective or Missing Arm Bands If the patient has no arm band or it is unreadable
you must Verify the patientrsquos identity and place a temporary band
on patient Request a new band from the Admitting Office Prior to removal of the temporary band and placement of
the new band have the patient -1 Verify the new arm band for accuracy and 2 Intial the arm band
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Infant Banding Four part neonateparent band identification
system 2 bands on neonate (2 different extremities) 1 adult sized band on mother 1 adult sized band on motherrsquos designee (father
partner support person) Any un-used bands will be destroyed
Note Some exceptions exist for NICU
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NICU BandingCritically ill neonates place in warmers or
isolettes for treatment are exempt from the banding requirement For those working in NICU additional measures are
taken to ensure identify of neonate and motherdesignated othersmdashplease discuss with preceptor
Two bands must be in place when the neonates are moved from bedside
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Patient IdentificationIn Star a ldquoamprdquo or ldquo+rdquo will be next to patientrsquos name denoting no information is to be given out
Cerner ndash Privacy
Denoted by gold Star
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Name Alert Patients with the same name or similar names
admitted to the same unit will be identified withLaminated Name Alert Sign placed over both
patientrsquos bedsLarge Name Alert Stickers placed on both patientsrsquo
charts (spine and cover) amp assignment board Small Name Alert Stickers placed on both patientsrsquo
Care Organizer amp arm band
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Advance Directives
1 The Physician enters ldquoDNRrdquo order in Cerner2 DNR Status will show in Bedside Summary
ldquoDo Not Resuscitaterdquo 3 The nurse places the purple DNR wristband on the patient4 At each shift hand-off the DNR status is communicated between the two nurses--both nurses visualize the purple DNR wristband on the patient during bedside report5 If a physician cancels or suspends the Do Not Resuscitate order The DNR order must be discontinued in Cerner The nurse removes the purple DNR wristband The nurse communicates the status change at shift hand-off
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NPSG Improve the Effectiveness of Communication Among Caregivers
NPSG020301 Report critical results of tests and diagnostic procedures on a timely basis
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Critical ValuesTestsCritical values are
diagnostic valuesresults considered life threatening or requiring immediate action
Test or diagnostic exam for which the result must be called regardless of value in order to effectively treat the patient
Nursing personnel must report the critical result to the patientrsquos physician within 30 minutes of receiving the critical result(TJC Required)
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Critical Value Documentation
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Telephone Orders Only licensed certified or registered professionals
representing BHS receive and verify telephone orders Ie RN LVN LSW Pharmacist LPTrsquos etchellip
Accepted only from BHS Medical Staff Allied Health Professional with privileges No paramedical personnel permitted to give orders Ie Office Nurse
Verbal Orders are allowed only during procedures VOrsquos in non-emergent situations when the prescriber is present are not acceptable
Two Patient Identifierrsquos Name and Account Number used for accuracy
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Telephone Orders
ENSURE ACCURACY
bull Enter order in Cerner Orders while Physician remains on the phone
bull Read the order back and include the prescriber name
bull Receiving confirmation from the prescriber that the order correct
bull Nurse then signs and activates order
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Telephone Orders
NO Verbal Orders will be taken forbull Chemotherapy
bull Do Not Resuscitate (DNR)Telephone orders can be obtained for DNR
with two nurses witnessing the order(s)
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Hand off Communication There is a high potential for errors at hand off Errors can occur at the change of shift report when patients are transferred tofrom tests and
procedures All Hand-off reports are documented in Cerner Use the ldquoHand Off Bedside Summaryrdquo in Cerner
when transferring care to another provider
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Bedside Handoff Summary
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Communication ToolsThe Patient Tracking Log is to be used each time the patient leaves for a medical testprocedure and when patients with Hospital Privileges leave the unit
The Ticket to Ride Form provides critical patient information for personnel caring for patients during diagnostic testing The nurse sending the patient provides information on this form to communicate the care the patient will require while off the unit
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Ticket to Ride Form
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Communicating Nursing Plan of Care
bullPeer checking at hand-off of the individualized nursing plan of care
bullPatient (Mr L Garza 67yo wshortness of breath)
bullPlan (Treatment Plan)
bullPurpose (WHY)
bullProblem(s) (Any contributingCo morbid conditions)
bullPrecautions (alerts critical values fall risk isolation test results specific procedural concerns)
Peer Checking
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
The 5 P for Plan of care are
A Problem Personnel Patient Precautions Plan
B Patient Problem Pain Precautions Plan
C Patient Plan Purpose Problems Precautions
D Patient Personnel Purpose Problem Plan
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
DocumentationCommunication Issues
The patient record is used as a communication tool for the multidisciplinary group care planning and consistency in care
The Joint Commission has requirements for inpatient documentation
Documentation inconsistencies found with diabetes nutritional risk pressure ulcer(s) depression and infant circumcision
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Measures of Success Challenges
38 of time the meal consumption was not documented
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Interdisciplinary Care Planning In the Baptist Health System the patient is treated by an
interdisciplinary team of professionals that collaborate with the patient and family to plan for the care of patients in a way that will maximize the patientrsquos outcomes
Goal-directed plans are documented by each discipline and shared with the team in the patientrsquos record andor care conferences to ensure coordination of care
The patientrsquos Plan of Care is updated daily or more often as determined by patient need response to care or change in condition
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NPSG Improve the Safety of Using Medications
NPSG030401 Label all medications medication containers and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG030501 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
NPSG030601 Maintain and communicate accurate patient medication information
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Labeling MedicationsSolutions on amp off the Sterile Field Label all medications medication containers
and other solutions on and off the sterile field Labeling occurs when any medication or
solution is transferred from the original packaging to another container even if there is only one medication being used
Applies to surgical and bedside procedures Examples syringes medicine cups basins
etc Policy RM-PS-12
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Guidelines for Labeling
Label must include -drug namestrengthamountexpiration date (when not used within 24 hours)expiration time
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Guidelines for Labeling cont
If an unlabeledsolution is found it is immediately discarded
All original containers remain available for reference until the conclusion of the procedure
All labeled containers discarded at the conclusion of the procedure
At shift change or break relief all medications amp solutions and their labels are reviewed by entering and exiting personnel
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Examples of Errors When Solutions Were Not Labeled
Chlorhexidine injected into an artery instead of contrast media in interventional radiology Result death
A preservative was confused with another solution (both solutions in unmarked containers) and injected intrathecally Result death
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Reduce Harm from AnticoagulantsBHS has a system-wide plan to provide
individualized plan to each patient receiving anticoagulant therapy to addressPhysician enters order in Cerner OrdersHigh alert medications require double
check of dosingAppropriate agent is usedMonitor the response to therapy labsDose adjustmentsPatient and family education
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Which medicine is not an anticoagulant
A Xarelto (rivaroxaban)
B Pradaxa (dabigatran)
C Epixaban( Eliquis)
D Celebrex (Celecoxib)
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Medication ReconciliationMedication Reconciliation Process is
established to accurately and completely reconcile medications across the continuum of care outpatient to inpatient
A complete list of the patientrsquos medications is communicated and provided toThe patientfamily on discharge from organizationThe next provider of service when dischargetransfer
is to another level of care or to another facility
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Medication ReconciliationOn admit the nurse documents all medications
(name dose route frequency indication and datetime last dose taken) that the patient is currently taking in Cerner
The admitting physician will review each medication and select medications to continue or to STOP in Cerner Medication Reconciliation
On discharge the Physician MUST enter the discharge medication reconciliation in Cerner
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Documenting medication reconciliation should be done
A At discharge
B Admission
C Readmission
D All of the above
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Adverse Drug Reactions (ADRrsquos)
Adverse Drug Reactions Any response to a drug that is noxious and unintended which occurs at doses normally used in man for prophylaxis diagnosis therapy of disease or for medication of physiological function (WHO)
Procedure Evaluate and monitor patient notify physician Reporting Use online occurrence reporting system
(MIDAS located on BHS Intranet)
Pharmacy and other key personnel will review all ADRs
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Sound-AlikeLook-Alike Drugs
Pharmacy assists us to identify review and prevent errors involving sound-alikelook-alike drugs (SALADs) by placing eyeglass or ear stickers on the drawer in Omnicell
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NPSG Use Alarms Safely
NPSG060101 Make improvements to ensure that alarms on medical equipment are heard and responded to on time
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Many patient care areas have numerous alarm signals The resulting noise and displayed information tends to desensitize staff and can cause them to miss ignore or even disable the alarms This is often referred to as ldquoAlarm Fatiguerdquo
Use Alarms Safely
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Reduce unnecessary alarms Ensure that alarms are heard and responded to
promptly Educate about the purpose and proper operation of
alarm systems
Use Alarms Safely
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
NPSG Reduce the risk of health care associated infections
NPSG070101 Comply with CDC or WHO hand hygiene guidelinesNPSG070301 Use proven guidelines to prevent infections that are difficult to treatNPSG070401 Implement evidence-based practices to prevent central line-associated blood stream infectionsNPSG070501 Implement evidence-based practices for preventing infection after surgeryNPSG070601 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Infection Prevention TeamThere are Infection Preventionists (IP)
throughout the Baptist Health SystemThe facility specific IP is on call 24 hrNo call is ever a wasted call ndash they want
you to call
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Hand Hygiene It is the single most effective way to
stop the spread of infection Itrsquos the first step toward patient safetyHand hygiene saves lives
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Hand HygieneOnly use hospital approved hand lotionUsing lotion brought from home may
compromise the integrity of gloves and other product used in the hospital setting
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Things You Frequently Touch
Stethoscope Keyboard Cell phonecases Charts Phones Pens Med cartAll of these can potentially transmit
microorganisms
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
DRY TIMES (ldquoKILL TIMESrdquo) FOR PRODUCTS USED IN DISINFECTINGCLEANING
For Sani-WipesAllow 2 minutes
to dry
For BleachAllow 4 minutes
to dry
For EVS cleaning of rooms Allow 10 minutes to dry
Super Sani-Cloth (Purple top germicidal disposable wipe)
bull Used to clean equipment keyboards phones tabletops charts etc
bull Wear gloves when cleaning disinfecting and deodorizing non- porous surfaces
bull Use thoroughly on the surface for 2 minutes
bull Do not keep this containerin the patientrsquos room These must not be
accessible to the public
Bloodborne Pathogen Exposure Baptist Health System has a
Exposure Control Plandesigned to eliminate or minimize exposure to bloodborne pathogens
Work which exposes employees to bloodborne pathogens is performed in accordance with the Occupational Safety and Health Administration (29CFR 19101030)
Bloodborne Pathogen Exposure Control Standard Precautions means that we treat all
human blood and certain human body fluids as if known to be infectious for HIV HBV and other bloodborne pathogens
Bloodborne Pathogen Exposure Control
Exposure risk is determined by reviewing employee positions for reasonably anticipated risk of occupational exposure to human blood body fluids or other potentially infectious materials as defined by the Bloodborne Pathogens Standard and OSHA interpretations
Bloodborne Pathogen Exposure ControlContact with bloodborne pathogens can be Direct- splash splatter or direct contact Indirect- touch a contaminated object or surface and then touch
eyes nose mouth or broken skin
Mechanisms of Exposure puncture wounds- leading cause of exposure among
healthcare workers broken skin contact- wounds cuts and broken skin contact with mucous membranes-eyes nose or mouth
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Baptist Health System has a
Exposure Control Plandesigned to eliminate or minimize exposure to bloodborne pathogens
Work which exposes employees to bloodborne pathogens is performed in accordance with the Occupational Safety and Health Administration (29CFR 19101030)
Bloodborne Pathogen Exposure Control Standard Precautions means that we treat all
human blood and certain human body fluids as if known to be infectious for HIV HBV and other bloodborne pathogens
Bloodborne Pathogen Exposure Control
Exposure risk is determined by reviewing employee positions for reasonably anticipated risk of occupational exposure to human blood body fluids or other potentially infectious materials as defined by the Bloodborne Pathogens Standard and OSHA interpretations
Bloodborne Pathogen Exposure ControlContact with bloodborne pathogens can be Direct- splash splatter or direct contact Indirect- touch a contaminated object or surface and then touch
eyes nose mouth or broken skin
Mechanisms of Exposure puncture wounds- leading cause of exposure among
healthcare workers broken skin contact- wounds cuts and broken skin contact with mucous membranes-eyes nose or mouth
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Control Standard Precautions means that we treat all
human blood and certain human body fluids as if known to be infectious for HIV HBV and other bloodborne pathogens
Bloodborne Pathogen Exposure Control
Exposure risk is determined by reviewing employee positions for reasonably anticipated risk of occupational exposure to human blood body fluids or other potentially infectious materials as defined by the Bloodborne Pathogens Standard and OSHA interpretations
Bloodborne Pathogen Exposure ControlContact with bloodborne pathogens can be Direct- splash splatter or direct contact Indirect- touch a contaminated object or surface and then touch
eyes nose mouth or broken skin
Mechanisms of Exposure puncture wounds- leading cause of exposure among
healthcare workers broken skin contact- wounds cuts and broken skin contact with mucous membranes-eyes nose or mouth
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Control
Exposure risk is determined by reviewing employee positions for reasonably anticipated risk of occupational exposure to human blood body fluids or other potentially infectious materials as defined by the Bloodborne Pathogens Standard and OSHA interpretations
Bloodborne Pathogen Exposure ControlContact with bloodborne pathogens can be Direct- splash splatter or direct contact Indirect- touch a contaminated object or surface and then touch
eyes nose mouth or broken skin
Mechanisms of Exposure puncture wounds- leading cause of exposure among
healthcare workers broken skin contact- wounds cuts and broken skin contact with mucous membranes-eyes nose or mouth
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure ControlContact with bloodborne pathogens can be Direct- splash splatter or direct contact Indirect- touch a contaminated object or surface and then touch
eyes nose mouth or broken skin
Mechanisms of Exposure puncture wounds- leading cause of exposure among
healthcare workers broken skin contact- wounds cuts and broken skin contact with mucous membranes-eyes nose or mouth
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Control Protect Yourself Follow procedures to reduce splashing
spraying and splattering of blood or body fluids
Never eat drink apply cosmetics handle contact lenses or store fooddrink in work areas containing blood or other body fluids that put you at risk for exposure
Transport specimens in closed leak proof containers
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Control If your scrubs become contaminated with
blood or body fluids Notify your DirectorManager and Linen
Environmental Services (EVS) LinenEVS will provide you with scrubs and a
laundry ticket Place article in a bag attach completed laundry
ticket and give to LinenEVS
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure ControlUse designated containers for sharps disposalDonrsquot bend break or re-cap needles Put sharp objects needles and broken glass in
sharp containerContainers are replaced by a contracted service
every TuesdayDo not allow these to become over filled If you notice a container needs to be changed
notify EVS
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Bloodborne Pathogen Exposure Control If you have been splashed cut or stuck by infectious
materialWash the area thoroughly with soap amp waterReport the exposure immediately to your supervisor
go to the employee health nurse (if on duty) after hours contact the house officer
Complete an Occurrence Report located in the BHS Intranet
You will be directed as of the next steps by Health Nurse or House Officer
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
What do you not do when you are stuck by a dirty needle
A Wash hands put a Band-Aid and continue caring for the patient
B Fill out occurrence report
C Report exposure to house officer
D Wash with soap and water
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Biohazard Waste The biohazard symbol warns that contents may cause
infection Place regulated biohazard waste in properly marked
red plastic biohazard containers
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Disposing of Biohazard Waste Regulated Biohazard Waste is - liquid or semi-liquid blood or other potentially infectious
materials potentially infectious materials in a liquid or semi-liquid
state that would release blood or if compressed items that are caked with dried blood or other potentially
infectious materials and are capable of releasing these materials during handling
contaminated sharps pathological and microbiological wastes containing blood
or other potentially infectious materials Place all other waste in the regular trash
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
All blood and body fluid should be treated as possiblyinfectious
Transmission Based and Standard Precautions are used with patients infected or colonized with infectious agents
Donrsquot forget to order the isolation cartBefore entering a patient room read the precaution sign on the door follow the instructions given and wear the appropriate PPE If you are not sure Ask Questions
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Use of the Isolation Cart Personal Protective
Equipment (PPE) must be kept stocked on the isolation cart
Reorder supplies as needed from Central Supply
Remove these items from the cart and place in the patient room Stethoscope Thermometer (digital) Blood pressure cuff
(disposable)
Remember to place the patient isolation sticker on the chart
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Airborne Infection Isolation PrecautionsSTOP
Wash hands or use hand sanitizer before enteringand before leaving room
Put on N95 mask before entering room Visitorssee nurse for instructions
Keep door closed
Visitors must go to nursing station before entering room
Precauciones Ambientales
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse mascaras al entrar al cuarto Mantengan la puertacerrada
ALTO
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Infections Requiring Airborne Infection Isolation Precautions Tuberculosis Pulmonarylaryngeal (suspected or confirmed)Extrapulmonary with draining lesion (with Contact)
Measles Monkeypox (with Contact) SARS (with Contact and Droplet) Smallpox (with Contact) Varicella (chickenpox)Disseminated ZosterLocalized in an immunocompromised person
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Which organisms require airborne precautions
A Measles mumps amp ruebella
B Chickenpox amp Measles
C EColi
D Influenza
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Tuberculosis (TB) Control Plan
TB is spread by airborne droplets All new employees must have a TB test
when they start and then every year If a patient has TB you must wear a N-95
mask respirator if you enter their room not just a plain surgicalisolation mask
TB mask respirators must be fit-tested TB Risk Assessment is performed annually
to determine risk category for the facility and for staff
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Droplet Precautions
Wash hands or use hand sanitizer before entering and before leaving room
Put on mask before entering roomVisitors see nurse for instructions
Visitors must go to nursing station before entering room
Precauciones de Secreciones Respiratorias
Los visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse maacutescaras al entrar al cuarto
STOP ALTO
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Infections Requiring Droplet PrecautionsAdenovirus pneumonia (with Contact)Haemophilis influenza type B (invasive
including meningitis pneumonia epiglottitis and sepsis)
Influenza (seasonal and pandemic) Neisseria meningitidis (invasive including
meningitis pneumonia and sepsis)Diphtheria (pharyngeal) Influenza (seasonal and pandemic) MumpsMycoplasma pneumonia
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Infections Requiring Droplet Precautions Parvovirus B19 Pertussis (whooping cough) Plague pneumonic Rhinovirus Rubella SARS (with Airborne and Contact) Streptococcal disease group A pharyngitis
pneumonia scarlet fever (infants and young children) major skinwoundburn (with Contact) serious invasive
Viral hemorrhagic fevers (Lassa Ebola Marburg Crimean-Congo) (with Standard and Contact)
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Contact PrecautionsVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wash hands or use hand sanitizer before entering and beforeleaving room
Wear gloves when entering roomcubicle
Wear gown when entering roomcubicle
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
ALTOSTOP
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Infections Requiring Contact Precautions Conjunctivitis Diarrhea Multi-drug resistant organisms includingMRSA VRE MDRSP MDR- GNB ESBLs VISA
and VRSA Rotavirus Skin infections that are highly contagious In Children the adenovirus bronchiolitis congenital
rubella furunculosis Respiratory Syncytial Virus (RSV) parainfluenza enteroviral infections neonatal herpes simplex
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Contact Precautions EnhancedVisitors must go to nursing station
before entering room
Precauciones de ContactoLos visitantes deben presentarse primero al puesto de enfermeria antes de entrarLaacutevense las manos Poacutenganse guantes al entrar al cuarto
Wear gloves when entering roomcubicle
Wash hands with soap and water beforeentering and after leaving room
Use patient-dedicated equipment or single-use disposable equipment Clean and disinfect all equipment before removing from environment
STOP ALTO
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Contact Precautions Enhanced Used for patients with suspected or confirmed C
difficile Also to be used if patient has diarrhea of unknown
cause and wears diapers or is incontinent Must use soap and water for hand hygiene not
alcohol based products
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Pain Management
Not specifically a NPSGmdashbut key component of Hospital Consumer Assessment of Healthcare Providers (HCAHPS)
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
It must always be our mission to safely reduce the incidence and severity of the patientrsquos pain and increase patient satisfaction with pain relief
Pain must be assessed in all patients Assessment should be appropriate to patientrsquos
conditiontreatment Pain management should included regular reassessment and
follow-up if needed The correct assessment method that is appropriate to patientrsquos
age andor abilities should be used How we and our patients think about pain is the key
to effective pain management
Pain Assessment and Management
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Comprehensive Pain AssessmentAssessment of pain must be done by a licensed
clinician regardless of where patient enters system Nursingmdashinpatientoutpatient Physical Therapy
Nurses must - Educate patients and their families about the need to
communicate unrelieved pain so they can receive prompt evaluation and effective individualized treatment
Identify and reduce barriers to effective pain management Provide post-discharge pain management plan and
instructions
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Assessment Tools for Neonates
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Establishing a Pain Goal This is often difficult for the patient Explain as a comfort or function goal Try questions
like How much pain can you tolerate and still be fairly
comfortable How much pain can you tolerate and still be able to get up
and walk around etc If the patientrsquos goal is not reasonable (eg 0 for a
patient going to surgery) take the opportunity to educate the patient regarding pain
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Regular ReassessmentFollow-up1 Nurse assess for pain every shift and within 1 hour of
giving pain medication Assessments and re-assessments must be consistently
documented on the patient care record Pain assessment should be done at the time of the physical
assessment and with hourly rounding PTOT assess pain prior to and after therapy as
appropriate PCATechs vital to early notification of pain
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
After pain medication administration assessment should be done
A At least 15 minutes after
B At least 30 minutes after
C At least 5 minutes after
D Within 1 hour
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Practice Pain Assessment
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Patient Peggyrsquos Dilemma
History of chronic low back pain Post-op day 1 sp knee replacement BP 14080 HR 88 R 20 T 991
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Pain3wmv
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Did Peggy Receive Proper Pain Management How would you describe the nursesrsquo attitude toward
Peggy Peggyrsquos behavior is most likely Drug seeking behavior commonly exhibited by patients
who are addicted or likely to become addicted or A typical response to the delays she has experienced in
receiving pain medication andor caused by poor pain control
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Reduce the Risk of Harm Resulting From Falls
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Basic Fall Intervention Plan1 Place call light and frequently used items within reach of
patient2 Maintain bed in low position3 Maintain wheelchair and bed in locked positions at all times4 Provide non-skid slippers for patients without safe footwear5 Remove trip hazards6 Educate patient and family regarding increased risk for injury
related to change in environment or weakness due to illnessinjurymedicationbed rest
7 Continually monitor patient activity8 Hourly Rounding
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Hourly Rounding Always check the six ldquoPrsquosrdquo of rounding
Pain (ldquoHow is your painrdquo)
Potty (Do you need to go to the bathroomrdquo)
Position (ldquoAre you comfortablerdquo)
Possessions (please keep the patients belonging within reach)
Pump (is an infusion pump beepingalarming)
Privacy (Is the patientrsquos privacy maintained)
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
High Risk Fall Intervention Plan Initiate high-risk interventions for each patient scoring
forty-five (45) or greater on the Morse Fall Risk ToolThese interventions may include but are not limited to
1 Apply a Fall Risk armband to patient2 Provide a Low Rise bed for patient3 Flag as ldquopriorityrdquo for call light response at the nurses station 4 Initiate risk-specific interventions based on the Falls Risk
AssessmentYELLOW is the color to denote fall risk at BHS and all
San Antonio hospitals
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
When Patient is Found on the Floor
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
When a Patient Falls When a patient falls dial 55555 and ask the
operator to announce a ldquoCode YELLOWrdquo At a minimum the response team includes House Officer Unit DirectorClinical Manager Charge NurseShift Supervisor (or designee) Nurse amp PCA assigned to patient
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Post Fall Follow-up The patientrsquos physician is to be notified of the fall
event as soon as possible Reassess fall risk and initiate additional interventions
that may be needed to reduce the risk of another fall The patientrsquos family is to be notified of the fall event
as soon as the patientrsquos immediate care and safety needs have been addressed An alert and oriented patient may request that the family not be notified this request must be documented in the patient care record
The fall episode is to be documented in Midas Risk at the time of the event by the nurse caring for the patient
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
NPSG The organization identifies safety risks inherent in its patient population
NPSG 150101 Identify which patient are most likely to commit suicide
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Psychiatric Patients in the ED Patients presenting with a primary co emotional or
behavioral disorders will be assessed for risk of suicide amp homicide
Emotional or behavioral disorders such as depression thoughts of suicide anxiety hearing voices overdose etc
It is recommended psychiatric patients be placed in treatment rooms in central area(s) of the ED in an area(s) where close frequent observation is optimized and away from egresses
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Patient and Room Safety1 Remove all sharps or potentially dangerous
itemsequipment from the patientrsquos room2 Place patient in green paper scrubs3 Inspect all belongings and clothing for items that can
be used to harm self or others4 Complete personal effects inventory sheet and have
security to secure patientrsquos valuables5 Patients hands must be in sight6 A qualified competent BHS employee must be the
11 observer 7 A family friend or outside facility representative of
patient may be allowed to stay in treatment room but will not be considered to be the observer
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Items Not Allowed to Stay with Patient All patient belongings
including their clothing Any hidden matches
cigarettes lighters amp aerosol spray nail polish or liquids
Any stuffed animals Any home medications
Remove needles razors paperclips and instrument packs
Remove gloves Any corded equipment
if possible Any glass amp unattached
mirrors are removed Only plastic cutlery for
meals and be sure to remove plastic knife
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Whatrsquos wrong with using this
room for a patient on Suicide
Homicidal precautions
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Suicide Precautions Outside the Behavioral Health Unit If a psychiatric patient is not in the Behavioral Health
Unit they must have continuous 11 observation by an observer who has completed observer training (PCA PCT ER and BHS Techs) or suicide precaution training (RNLVN)
The observer must be at the bedside and visually observe the patient at all times
Patientrsquos hands must be in sight at all times Observer may not leave patientrsquos room unless relieved
by another qualified competent observer
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Suicide Precautions Outside the Behavioral Health Unit If patient leaves the Behavioral Health Unit they must
be accompanied and have continuous 11 observationby a competent observer
Family or other visitors allowed but are not to be used as observers
House Officer must be notified of all 11s Physicianrsquos order is required to discontinue suicide
precautions
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
This checklist is used for SuicideViolentBehavior Precautions documentationbull The following must be
documented every 15 minutesbull BehaviorMoodbull Activitybull Location
bull Observer must initial after each entry
bull Safe Room checklist is on the back of the form
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Continuous Observation Record for SuicideViolentBehavior (continued)bull The RN must assess the
patientrsquos safety status every 2 hours When the RN performs the safety check the observer will document this by using the ldquoSrdquo code
bull A safety check of the room must also be documented every shift
bull Both the observer and RNmust sign with their initials full signature shift amp employee number
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Evaluation amp Transfer The ED physician andor advanced healthcare
practitioners will evaluate the patient and determine the need for a psychiatric evaluation
The patient must be medically cleared prior to transfer to appropriate psychiatric unit
The ED physician or the patientrsquos psychiatrist will refer and arrange transfer to the psychiatric unit
If patient is a danger to self others or a flight risk a qualified competent BHS employee will be requested to continually observe the patient
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Additional Resources
The following resources can be found in the patient handbook Center for Health Care ServicesAdult Crisis Center (210) 225-5481Childrenrsquos Crisis Center (210) 299-8139
Camino Real Community MHMR Center (800) 543-5750
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Who can be a sitter for suicide precautions
A Chaplain
B Qualified competent sitter
C Sister
D Volunteer
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Core Measures and Getting with the Guidelines
Brief overview for New Hire General Orientation
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Core Measures are a set of care standards required by the Centers for Medicare amp Medicaid Services (CMS) which describes the care to be provided to our patients while in the hospital These care standards have been shown through scientific evidence to improve patient outcomes
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Each Hospital have core measure nurses who audit medical records of patients admitted with core measure diagnosis
These diagnosis change based on CMS criteria for reporting
Documentation fall outs cost the hospital in CMS reimbursements for services provided
Additional diagnosis or indicators may be audited based on hospital improvementgoal tracking of previous reportable core measures Ex CHF AMI Afib etchellip
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
CORE MEASURE What WeTrack
Emergency Department Time from Arrival to Departure for AdmissionTime from decision to admit to ED departure
Immunizations Influenza Immunization
Perinatal Care Elective delivery prior to 39 weeks gestationExclusive Breast Milk Feeding
Sepsis Severe Sepsis and Septic Shock management bundle
Stroke VTE prophylaxis by end of hospitalization day 2Discharged on antithromboticAnticoagulant for AfibFlutterThrombolytic TherapyEarly Antithrombotic TherapyStatin on DischargeStroke EducationRehab Evaluation
VTE (Venous Thromboembolism) VTE prophylaxis by end of hospital day 2Warfarin therapy discharge instructionsHospital acquired potentially preventable VTE
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
AMI A-fibA-flutter and CHF all have specific forms that MUST be completed BEFORE discharge Information on these charts are obtained by the physician primary nurse and Core Measure Nurse and completed BEFORE discharge
Upon admission the core measurenurse will review the record and put the appropriate needs form in the medical record Start working on the requirements before discharge All measuresMust be met and the discharge reviewed byCore Measures Nurse prior to patient discharge
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Hospital Core Measure Nurses Contact Number
Baptist Medical Center Lettie Martinez 297-7398
North Central Baptist Andrew Snell 297-4964
Northeast Baptist Shelley Holmes 297-2894
Mission Trail Baptist Diana Guzman 297-3731
St Lukes Baptist Mindy Dyer 297-6195
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Delegation amp Supervision Understanding RN Responsibilities
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Role and Scope of Practice for the RN
The role and scope of practice of the Registered Nurse is clearly delineated in the American Nurses Association Code for Nurses and Interpretive Guidelines
The Texas Nursing Practice Act httpwwwbontexasgovnursinglawnpahtml and the Texas Administrative Code 21711 Standards of Nursing Practice is the law pertaining to RN Practice
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Assignment Guidance
Texas BON Position Statement 1527 The Texas Board of Nursing (BON) is authorized by the
Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely The Texas Nursing Practice Act (NPA) and the Boardrsquos Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN)
The BHS policy Scope of Practice NURS-AD-09 provides guidance on the roll of the LVN at Baptist Health System
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Texas BON Position Statement 1527 The LVN Scope of Practice
The LVN is responsible for providing safe compassionate and focused nursing care to assigned patients with predictable health care needs The term predictable describes health conditions that behave or occur in an expected way It ldquodoes not mean that the patient is always stablerdquo
ldquoPredictable health conditions follow an expected range or pattern that allows the LVN with hisher clinical supervisor to anticipate and appropriately plan for the needs of patientsrdquo
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Texas BON Position Statement 1527 The LVN Scope of Practice
Supervision LVN functions under the supervision of a RN APRN physician physician assistant podiatrist or dentist Supervision Active process of directing guiding and
influencing the outcome of an individualrsquos performance of an activity
The LVN is precluded from practicing in a completely independent manner
It is ldquothe LVNrsquos responsibility to ensure he or she has an appropriate clinical supervisorhelliprdquo
The LVN may not practice in a ldquocompletely independent mannerrdquo
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
LVNsrsquo Role in the Nursing Process
Assessment Planning Implementation Evaluation
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Assessment
The LVN assists contributes and participates in the nursing process by performing a focused assessment on individual patients to collect data and gather information
A focused assessment is an appraisal of the situation at hand for an individual patient and may be performed prior to the RNrsquos initial and comprehensive assessment
The RNrsquos comprehensive assessment is the initial and ongoing extensive collection analysis and interpretation of data
LVN collects data and information recognizes changes in condition and reports this to the RN supervisor
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Assessment The Admission Record or an electronic data
collection tool is initiated on admission and is completed by a RN within 24 hours of admission
The RN must do immediate postoperative assessments This assessment cannot be assigned to the LVN As directed by the RN the LVN monitors patient for complications related to anesthesia and those specific to the type of surgery
LVNs may not make the final determination from their assessments that the patient is in need of initiation or continuation of restraint
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Planning
The LVN assists the RN in the development and revision of the plan of care
Reviews the plan of care daily with the RN Initiation of the Plan of Care must be done by the
RN and cannot be delegated or assigned
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Implementation LVNs documents care given Updates the supervising RN about the patientrsquos
condition at least once a shift or whenever there are changes in the patientrsquos condition or new orders received
Reinforces teaching done by RN Implements the teaching plan for clients with
common health problems and well defined learning needs
Adapts care procedures based on age specific requirements
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Evaluation The LVN assists in the evaluation of patientrsquos
responses and outcomes to therapeutic interventions
Documents response to treatment in medical record Reports all changes in condition to the RN and to the
physician as directed by the RN Meet at least once a shift with RN (or whenever
patient condition changes) to evaluate the patientrsquos response to treatment and discuss needed changes in the plan of care
Participates in discharge planning activities and discharge education as directed by the RN
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
RN Responsibilities When DelegatingAssigning
Delegation is to the Unlicensed Personnel and Assigning is to the Licensed Vocational Nurses is an essential function of the Registered Nurse
Delegation or assignment passes on the responsibility for performing a task but not the accountability for the process or outcome of the task When nursing activities are assigned the RN is responsible for assessing planning and supervising the implementation of those activities
Evaluation of the outcomes cannot be delegated by the RN The RN must provide supervision based on staff members
experience levelclients needs
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Factors that Affect the Decision to Assign a Nursing Activity1) The potential for harm to the patient2) The complexity of the task to be performed3) Problem-solving skill and creativity required to
achieve a successful outcome4) The unpredictability of the activityrsquos outcome5) Level of patient interaction required6) Level and preparation of the staff expected to
accomplish the activity7) State law8) Institutional policy
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
When Making Assignments Patient needs must be the
priority for assignments The RN must consider the
staffrsquos scope of practice What are they allowed to do
The RN must consider the staffrsquos competency What competencies have they completed If needed review staff competencies
Agency nurses or nurses floating to unit must provide same level of care
Assignments may need to change as the patientrsquos condition changes
Every patient must have an RN assigned to him or her 247 This means the RN supervising the LVN or PCA is ultimately responsible for their patient
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
What RNs May Not Assign to LVNs
LVNS MAY NOT - administer blood or blood products LVNs may
monitor a patient receiving blood AFTER the RN has monitored the patient during the initial 15 minutes of infusion
push IV narcotics other than meperidine hydromorphone morphine and furosemide via the IV push route but may only after successful completion of educational activities and competency evaluation
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
What RNs May Not Assign to LVNs LVNS MAY NOT -
Heparin bolus drip initiate PCA therapy May set up system and
check balances with a RN initiate titrate or push vasoactive medications give IV or PO chemotherapy agents give phenergan IVP add medication to an IV fluid but may serve as
2nd check for admixtures or initiate or perform any care related to the
epidural catheter
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
RNLVN Scope of Practice and Cerner Order Review
bull Any orders outside of the LVNrsquos scope to implement MUST be reviewed and implemented by the RN
bull LVN will only review orders that are within the LVNrsquos scope
bull In the event that the LVN has already performed the Nurse Review of an order that is outside of the LVNrsquos scope the RN still must review the order
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Routine Patients
Can the LVN assess hisher own patients
Does the RN have to co-sign the LVNs assessment
What does the RN document and where
RN must develop the plan of care and document the patientrsquos progress on the Nursing Plan of Care document or in the nurses notes The RN must review and sign the graphics for that shift
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
A LVN
B MD
C RN
D RN and LVN
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Who Is Responsible
LVN functions under his or her own license and assumes accountability and responsibility for quality of care provided to patient and their families according to standards of nursing practice
RN delegates appropriately
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Interdisciplinary Screening
If the Interdisciplinary Screening on the Admission Record identifies the need for a referral and an in-depth assessment by another discipline a referral will be made to that discipline by nursing or any member of the interdisciplinary team
Once referral is made each discipline completes an assessment within the allotted time frame usually 24 hours
Interdisciplinary screening is an RN responsibility and should not be delegated to the LVN
RNs are responsible for assessing the need for care from other members of the interdisciplinary team on an ongoing basis
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
Intranet Resources
Clinical Skills (formerly Mosbyrsquos) Micromedex Standard Order Sets Krames on Demand Education web site amp calendar Lots more in the Intranetmdashonce you have accessmdash
spend some time exploring if possible
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
-
SummaryConclusions Lots of information todaymdashgoal is exposuremdashwith
reinforcement to follow in future classesunit-level orientation
Thank you for choosing the Baptist Health Systemmdashthank you for taking care of our patients
- 2017 Hospital National Patient Safety Goals
- Personal Investment in Orientation
- Keeping Your Patients Safe
- NPSG 1 Improve the accuracy of patient identification
- Patient Identifiers on Lab Specimens
- Defective or Missing Arm Bands
- Infant Banding
- NICU Banding
- Slide Number 9
- Name Alert
- Slide Number 11
- NPSG Improve the Effectiveness of Communication Among Caregivers
- Critical ValuesTests
- Slide Number 14
- Telephone Orders
- Telephone Orders
- Slide Number 17
- Hand off Communication
- Bedside Handoff Summary
- Communication Tools
- Ticket to Ride Form
- Slide Number 22
- Slide Number 23
- The 5 P for Plan of care are
- The 5 P for Plan of care are
- DocumentationCommunication Issues
- Measures of Success Challenges
- Interdisciplinary Care Planning
- NPSG Improve the Safety of Using Medications
- Labeling MedicationsSolutions on amp off the Sterile Field
- Guidelines for Labeling
- Guidelines for Labeling cont
- Examples of Errors When Solutions Were Not Labeled
- Reduce Harm from Anticoagulants
- Which medicine is not an anticoagulant
- Medication Reconciliation
- Medication Reconciliation
- Documenting medication reconciliation should be done
- Adverse Drug Reactions (ADRrsquos)
- Sound-AlikeLook-Alike Drugs
- Slide Number 41
- NPSG Use Alarms Safely
- Use Alarms Safely
- Use Alarms Safely
- NPSG Reduce the risk of health care associated infections
- Infection Prevention Team
- Hand Hygiene
- Hand Hygiene
- Things You Frequently Touch
- Slide Number 50
- Super Sani-Cloth (Purple top germicidal disposable wipe)
- Bloodborne Pathogen Exposure
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- Bloodborne Pathogen Exposure Control
- What do you not do when you are stuck by a dirty needle
- Biohazard Waste
- Disposing of Biohazard Waste
- Transmission Based Precautions(Airborne Droplet Contact Contact Enhanced)
- Use of the Isolation Cart
- Airborne Infection Isolation Precautions
- Infections Requiring Airborne Infection Isolation Precautions
- Which organisms require airborne precautions
- Tuberculosis (TB) Control Plan
- Droplet Precautions
- Infections Requiring Droplet Precautions
- Infections Requiring Droplet Precautions
- Contact Precautions
- Infections Requiring Contact Precautions
- Contact Precautions Enhanced
- Contact Precautions Enhanced
- Pain Management
- Pain Assessment and Management
- Comprehensive Pain Assessment
- Slide Number 79
- Assessment Tools for Neonates
- Establishing a Pain Goal
- Regular ReassessmentFollow-up1
- After pain medication administration assessment should be done
- Practice Pain Assessment
- Patient Peggyrsquos Dilemma
- Slide Number 86
- Did Peggy Receive Proper Pain Management
- Reduce the Risk of Harm Resulting From Falls
- Basic Fall Intervention Plan
- Hourly Rounding
- High Risk Fall Intervention Plan
- When Patient is Found on the Floor
- When a Patient Falls
- Post Fall Follow-up
- NPSG The organization identifies safety risks inherent in its patient population
- Psychiatric Patients in the ED
- Patient and Room Safety
- Items Not Allowed to Stay with Patient
- Whatrsquos wrong with using this room for a patient on Suicide Homicidal precautions
- Suicide Precautions Outside the Behavioral Health Unit
- Suicide Precautions Outside the Behavioral Health Unit
- Slide Number 102
- Slide Number 103
- Evaluation amp Transfer
- Additional Resources
- Who can be a sitter for suicide precautions
- Core Measures and Getting with the Guidelines
- Slide Number 108
- Slide Number 109
- CMS Core Measure Indicators
- Getting with the Guidelines
- Slide Number 112
- Delegation amp Supervision Understanding RN Responsibilities
- Role and Scope of Practice for the RN
- Assignment Guidance
- Texas BON Position Statement 1527 The LVN Scope of Practice
- Texas BON Position Statement 1527 The LVN Scope of Practice
- LVNsrsquo Role in the Nursing Process
- Assessment
- Assessment
- Planning
- Implementation
- Evaluation
- RN Responsibilities When DelegatingAssigning
- Factors that Affect the Decision to Assign a Nursing Activity
- When Making Assignments
- What RNs May Not Assign to LVNs
- What RNs May Not Assign to LVNs
- RNLVN Scope of Practice and Cerner Order Review
- Routine Patients
- If an RN assigns a task or a patient to an LVN and the LVN does something wrong who is legally responsible for any negative outcome
- Who Is Responsible
- Interdisciplinary Screening
- Intranet Resources
- SummaryConclusions
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