Legacy House of Bountiful Med Tech Manual

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HIPPA Disclamer
All of the names that are used in this manual are ficitous and in no way reflect real people and their medical histories. Any refernce to a real person and their medical history was unintental.

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HIPPA Disclamer..................................................................................................................3 Preface...................................................................................................................................7 Glossary.................................................................................................................................9 Section One: Handling Medication...................................................................................13 Medication Cart Orination..........................................................................................15 Pulling Medication.....................................................................................................16 The Night Box............................................................................................................18 Passing Medications...................................................................................................20 Medication Errors.......................................................................................................20 Section Two: Documentation.............................................................................................22 Documenting Medications.........................................................................................22 Medication Administration Record (MAR).....................................................24 Documenting Narcotics..............................................................................................24 Narcotic Record................................................................................................24 Narcotic Card/ Narcotic Sheet Count...............................................................25 Documenting Residents Condition.............................................................................27 Daily Charting..................................................................................................27 Incident Reports...............................................................................................29 Taking and Recording Vital Signs..............................................................................32 Daily Vitals.......................................................................................................32 Daly Vitals in the MAR....................................................................................32 Blood Sugars....................................................................................................33 Oxygen Level (O2)............................................................................................33 Pulses and Blood Pressures..............................................................................34 Pulse in Mar......................................................................................................34 Using the Binders.............................................................................................35 Section Three: New Orders andOrdering From Pharmacies.........................................37 New Orders.................................................................................................................37 Ordering From The Pharmacy....................................................................................38 Superior Care Pharmacy...................................................................................38 Ordering Priority Medications...............................................................39 Ordering After Hours.............................................................................39 Mountian West Apothacary..............................................................................39 Other Pharmacies.............................................................................................39 New Order Checklist..................................................................................................40 Reorder Checklist.......................................................................................................40 Section Four: Emergency Situations.................................................................................41 First Aid......................................................................................................................41 Transporting to the Hospital.......................................................................................42 Employee Injury Procedure........................................................................................42 Hospital Procedure 3 4

Contents

 Building Evacuation...................................................................................................44 Death Procedures........................................................................................................45 Section Five: Outside Agencies..........................................................................................46 Home Health...............................................................................................................46 Hospice.......................................................................................................................46 Flex Care....................................................................................................................47 Section Six: Caring For Residents with Diabetes and Dementia....................................48 Residents with diabetes..............................................................................................48 Residents with dementia.............................................................................................49 Section Seven: Addtional Information..............................................................................50 Supplies......................................................................................................................50 Doctors Apointments.................................................................................................50 HIPAA.........................................................................................................................51 Appendices ..........................................................................................................................53 Appendix A: Common Narcotics and Antibiotics......................................................54 Appendix B: Symbols and Abbreviations..................................................................55 Appedix C: Conversion Chart....................................................................................57 Appedix D: Military Time..........................................................................................57 Appendix E: Residents Charts....................................................................................58 Appendix F: How to Use a Nebulizer........................................................................59 Appendix G: How to give a Suppository...................................................................59

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Preface
This manual was written to help better train the medication technicians(med techs) of Legacy House of Bountiful. This manual is tailored to the policies and procedures that are used in this facility. This manual is a comprehensive document that describes how to complete tasks that a med tech performs on a daily basis. It also provides examples of how to correctly fill out the documents that med techs are required to use. The goal of this manual is to have a more hands on approach to the training of new med techs, so that they are better prepared to work when their training is complete. Also, this manual is meant to be used as a reference manual for current med techs when they have questions.

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Glossary
Administrator AM (Shift): Assistant Administrator: Change in Status: Code (Full Code): Ekit: The person that is the director of the building. Also refered to as the Buliding Director. The med tech shift from 0600 to 1430. The manager that is over the aides and creates the schudule for the med techs and the aides. Any change in the residents condition, either for better or worse, which changes the assistance that the resident needs. This means that the resident has a full recitation order. If needed the med tech or aide would need to perform life saving measures, such as CPR A kit of medications for residents that are on hospice.The kit is provided by hospice.The medications are to be used for comfort measures and its use needs to be approved by the hospice nurse. Any resident on hospice needs to have an ekit. The cover sheet of a residents chart.This contains pertinent information such as birthday, emergency contact information and insurance information. A copy of this sheet needs to accompany the resident when they are sent to the hospital, another facility, or a doctors appointment. And if a lab specimen is taken the face sheet needs to accompany the specimen. The shift from 2200 to 0630. Stands for the Medication Administration Record.This is the record that is signed by the med techs to document the time and dosage of a medication given. Often referred to as the cart.The med cart is where the medication that the med techs administer are kept. It locks and has three narcotic drawers that also have a lock. This is the room where the medication and charts are kept.This is also where the Assistant Administrator has her office. The packaging that medication comes in from Superior Care. Also called auto med. Short for narcotic The vital sign that measures the amount of oxygen in the blood stream. A signed prescription from the doctor that can be for medication, a treatment or assessment for Home Health or Hospice. Sometimes is referred to as the DNR Order or simply the DNR.This is a legal document that states the residents DNR status.The POLST is kept in the back cover of a residents chart. The med tech shift from 1400 to 2230. Power of Attorney.This is a person that has legal power to make medical decisions for the resident when the resident is no longer able to make such decisions. The term that is used when sending an order to Superior Care, so that the order will appear on the MAR and Superior will not send the medication. Resident Care Coordinator.The nurse that is in charge of the med techs and coordinates resident care with outside agencies and the assistant administrator. Any syringe or lancet with a sharp edge.These need to be put in a sharps container either in the residents room or in the Med Room. ix

Face Sheet: Grave: MAR: Med Cart: Med Room or Wellness Center: Med Strip: Narc: O2: Order: PLOST: PM: POA Profile Only: RCC: Sharps:

Legacy House of Bountiful Med Tech Manual

By Amber Nielsen MT CNA

Section One: Handling Medication

The primary job of a med tech is handling of medications. To handle medications, all med techs need to have an understanding of the six rights of medication adminastration. All medication errors occur because one or more of these rights wasnt followed. The six rights are as follows: It is very important that each resident receives his or her own medications and not another residents medications. By double checking names on medication packaging and the resident, you insure that the right resident is recieving the right medication. If you are unsure, ask the resident his or her name, it is better insure accuracy than it is to look silly by asking a resident his or her name. Each dose of a medication has been assigned a specific time unless it is an as needed (PRN) medication. It is very important that all scheduled medication be given one hour before or after the scheduled time to insure that a resident isnt receiving too much of a medication too close together. Eventhough PRN medications dont have an assigned time, doses must be given a certain amount of time apart. (The order for the medication tells how long that amount of time should be.) By checking the assigned time on the MAR and giving medication at that time, you insure that the medication right is being recieved at the right time. Each resident has been prescribed specific medications by his or her doctor. It is the responsibility of the med tech to insure that each resident receives the right medication as prescribed as percribed by the doctor. Every perscibed medication has been assigned a specific dose. It is important to triple check medication when pulling it to insure that the right dose is given. Failure to receive the right dose of a medication can be detrimental to the residents health. For example, even if a coumadin dose is off by 0.5mg it can cause blood clotting issues.

Right Resident

Right Time

Right Medication Right Dose

Right Route Right Documentation

Each medication is prescribed a route, or place on/in the body that it is to be administered: by mouth (PO), by eye (gtts/ OU), by nose, by rectum. It is very important that a medication is delivered by the right route. (No one wants to swallow a suppository!) When handling medication you must correctly document that the pill was given, if it wasnt given you need to document why it wasnt given. Right documentation includes signing the pill out in the MAR; and if it is a narc signing out in the Narcotic Record Binder. If for some reason a pill is not given it, that needs to be documented as well. Remember if a pill isnt documented correctly as given then it wasnt given and is a medication error.

Medication Cart Orination

The medication cart, often called the med cart or cart, is where all of the medication is kept. There are two med carts, the big cart and the small cart. The big cart is kept in the Med Room. The small cart is kept in the cottage office during AM and PM shift; and it is moved back into the Med Room at the end of PM shift and kept there on the graveyard shift. Both carts are kept in the Med Room at night because they need to be kept in a locked room. Both carts are set up as follows: Top of the cart: The MAR Binder is kept on top of the med cart, along with a blood sugar schedule, and any important notices. The blood sugar schedule is a list of residents that need blood sugars taken and at what time the blood sugar needs to be taken. Top Drawer: The treatments are kept in the top drawer of the med cart. Treatments include eye drops, inhalers, nose sprays, and creams. All treatments are grouped together according to category. Pens, sharpies, small notebooks and the oximeter are also kept in the top drawer. Second Drawer: Beginning in the second drawer and continuing down as far as needed is where scheduled medication is kept. The scheduled medication is put in alphabtical order by the residents last name. Each resident has an auto med strip or med bubbles. Also, any non narcotic patches, any medications not in cards or the med packets, and ekits for hospice residents are kept with auto med/med bubbles. Any remaining drawers until the bottom drawer are where any medications that dont fit next to the medications packets are kept. Bottom Drawer: The bottom drawer is where medication cards are kept. The majority of these cards are PRN meds. However, there are a few meds that are scheduled and come in medication cards that are kept in the bottom drawer. If space allows powder medications, such as Miralax are also kept in this drawer. The medication cards in the bottom drawer in alphabetical order by the residents last name starting in the front of the drawer. A divider with the residents name is placed in front of his or her medication cards to keep resident medications seperate and help prevent medication errors. There is also a narc drawer in the bottom drawer. This narc drawer is when the narcs that come in ekits, liquid narcs (in sryniges) and patches are kept. (Basically any narc that is not packaged in a medication card is kept in the bottom narc drawer.) Side Drawers: Off to the side of the main drawers of the med cart are four smaller drawers. The top drawer contains both big and small med cups, med baggies, and pill crusher bags. The second and third drawer are narc drawers, they both have lock boxes that fill the entire space of the drawer, these drawers need to be locked at end of the PM shift. Narc cards are organized in alphabetical order by residents last name beginning in the back of the drawer. Dividers are also used to seperates the residents narc cards. Coumadin and antibiotics are also kept in the narc drawer. The fourth/bottom side drawer is where powder and extra supplies are kept. The top of the cart is where the MAR, blood sugar schedule and important notices are kept. The top drawer is where the treatments, pens and markers, and the oximeter are kept. The top side drawer is were the med cups and baggies are kept Begining in the second drawer all of the auto med strips or med bubbles are kept. The second and third side drawers are narc drawers. The bottom side drawer is were powder meds and extra sup plies are kept The bottom drawer is were med cards, powder and liquid meds, and the third narc drawer are kept.

Pulling Medication
Each med tech has his or her own way of pulling medications. Some pull all the pills that they will pass on their shift in one long pull and others pull according to the time that they will pass the pills. Whether you pull all of your pills at once or divide your pulls up, there are some important guide lines to remember. Medication packets, auto med strips (Superior) and med bubbles (Mountain West), are located in the med cart starting in the second drawer down beginning in alphabetical order by the residents last name. Printed on each med packet the residents name, the date and time that the packet should be administered, and the medications that are in the packet. Auto Med Strip When pulling medications, each medication that is listed on the packet, or on the medication cards in the narc drawer or bottom drawer must be triple checked against the MAR to insure that it is the RIGHT MEDICATION, RIGHT DOSE, RIGHT ROUTE, and is given at the RIGHT TIME and that the RIGHT MEDICATION is being pulled for the RIGHT RESIDENT. Any medications that you put into a plastic baggie or medication cup must have five things written on it: The residents name Scheduled time of the medication Name of the medication Dose of the medication Route of the mediction Any medication that is placed in a baggie and taped back on to a card must have four things written on it: The residents name The name of the medicaiton Dose of the medication Route of the medication Medications that are pulled need to be put into a purple box. These boxes are used to carry medication when passing. When you are pulling medications you will put the medication and any treatments needed into a purple box. Use a different purple box for each med pass. This keeps medication seperated and helps prevent giving a medication at the wrong time. The purple boxes need to be locked up until it is time to pass out the medication in them. Med Bubble

Marty Fenwick 2000 Coumadin 7.5mg PO Stan Walker Benadryl 25 mg PO

Purple Medication Box

The Night Box

During the graveyard shit there is no med tech on duty. Instead a grave med aide passes the medication on graveyard and any requested PRN medication. This medication is kept in the night box. And the medication that goes in the night box is pulled and prepared by the PM med techs. While the PM med techs prepare the medication that goes in the night box both AM and PM shifts have responsibilities with the night box.

AM Shift:

Check the night box with graveyard med aide. Any medication that is still in the night box needs to be written on the Night Box MAR. After the remaining medication is checked and documented both AM med techs and the graveyard med aide will sign the Night Box MAR. Receive a brief report from the graveyard med aide about any PRN meication given, any sheduled medication not given, falls and injuries, and if any resident was sent to the hospital. If a resident was sent to the hopital during graveyard that is on Flex Care the AM med tech will need to contact Flex Care and tell them that one of their residents has gone to the hospital. Receive 48 Hour Follow Ups, New Incident Reports, and any Records of Death from the graveyard med aide. Responsible for destroying any scheduled medication that was left in the nightbox and documenting on the Night Box MAR that the medication was destroyed. Use any left over PRN medication in the night box, if possible. If the PRN medication isnt used on AM shift, it can be left for the PM shift to use. Report any requested PRN medication to the PM med tech. Pull all of the scheduled medication for graveyard (between 2230 and 0700. In the MAR, graveyard medications are highlighted in purple); commonly used PRN medications and any new requested PRN medications. All medication needs to be labeled with the residents name, the medication name, dose, and time. Medication that is in auto med strips from Superior can be left in its packaging. Everything else needs to be placed in a baggie with a night box label. Destroy any PRN medication that wasnt used on the PM shift. Check the night box with the graveyard med aide and sign the Night Box MAR. Give a brief report to the graveyard med aide about PRN meds given and any other pertinent information. Give 48 Hour Follow Ups to the graveyard aide. To see a copy of the Night Box MAR go to page 8. 7

PM Shift:

15 Mg 5/500 Mg 25MG 10MG 25MG 15MG 7.5/325 mg 25/100 5/500 Mg 75 MG 75 Mcg 50 mg 60 Mg 75 Mcg

Zach Richards

7.5/500 15 Mg 5/500

Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards Zach Richards
02/12/12 2230
02/12/12 2230 02/12/12 2230

Zach Richards Zach Richards

Zach Richards

5 Mg 10 Mg

Zach Richards Zach Richards

Anglea Rodgers Riley James Zach Richards

PRN PRN PRN PRN 2230 0600

Thomas Lund Margret Simpson Nathtan Martin Joseph Peterson Lucy Marberry Audrey Thompson

Temazepam
Tylenol

Not Requested Percocet

Xanax Simvastatin Tramadol

Resident Refused

Not Requested Not Requested

Not Requested

Resident was Sent to the Hospital

Bill Richard James Perkins Mary Davis

Tylenol Lortab Lortab

Zach Richards
Brynn Thomas

02/13/12 0630

Rachel Fielding

02/13/12 0630

02/13/12 0630

This illstration shows the Night Box MAR and how to properly fill it out. The PM shift med techs will check the medication that they have pulled and put into the night box with the graveyard med aide. Once the medications are check and EVERY medication that is listed in the Scheduled and PRN columns are present, the med techs and graveyard med aide need to sign and date under the PM/ Graveyard Shift Change column. The graveyard med aide will fill the out the Night Box MAR as they give medication throught the night. If the there are any requests for PRN meds not in the night box, they will also record those.When AM Shift arrives, the graveyard med aide and the AM shift med techs will check the box and record any remaining medications. Once the medications are recorded along with the reason that they werent given, the graveyard med aid, and the AM shift med tech need to sign and date under the Graveyard/ AM Shift Change column.

Passing Medications
The MAR lists the times that scheduled medications need to be administered. You have an hour before or after that time to administer that medication. For example, if a medication is scheduled to be given at 1600, you may give it starting at 1500 and up until 1700. However, the two hour window doesnt apply to PRN Medications, especially narcotics. PRN medications need to be spaced according to the directions in the MAR. For example, if a PRN medication is every four hours and it is given at 1200, it cannot be given again until 1600. For scheduled medications there are five main pass times: 0800, 1200, 1400, 1600 and 2000. If for some reason a medication cannot be given between the two hour block allotted, it must be cleared by a nurse to give the medication. The exception that doesnt need to be cleared; is if a medication Remember that for all scheduled medication is missed at the 2000 (bedtime pass) because a resident is out there is a two hour passing window. of the building (during the 2000 pass) the medicaiton may be given up until 2400 without consulting with the nurse beforehand. When you are passing your medications it is very important that you double check the name on the medication packet and the actual resident that you are giving the medication. This insures that every resident is receiving the correct medication. (See The Residents Rights on page 3) If you are unsure of a residents name because they have just moved in, ask them their name. It is better that you ask the resident his or her name and not another resident or coworker to insure that you are giving the right resident his or her pills.

Medication Errors
A medication error occurs anytime that one of the six rights is not followed. Examples of med errors are: giving the wrong medication to the resident,not giving a medication at the right time, not giving a medication, or not properly signing out a medication. When a medication error occurs a Medication Error Report needs to be filled out and the proper people need to be informed. These people are the nurse, the residents doctor and the emergency contact person. In addition to filling out a medication Error Report, an Incident Report needs to be filled out and 48 Hour Follow up in needs to be started. Giving the wrong medication is an incident that can change the status of a residents well being and they need to be monitored to insure that no complications arise from receiving the wrong medication. To see how to correctly fill out a Medication Error Report go to page 10.

2/12/12
X X

Boyd, Fredrick
1600
X X Nurse okayed not calling

Thomas, Brynn

24/15/25
1630 1635 1640

2/12/12 2/12/12 2/12/12

George Garcia
X

Katlyn Smith

One lortab 5/500 mg every 4 hours as needed for pain.

instead of just one. The wrong dose of lortab was given.

I gave two 5/500 mg lortab at 1600

The residents vitals were taken at the time of the med error, and again an hour later and then three hours later per the nurses request. The staff will continue to
The resident for any changes.

98.7 85 22 160/80 95 116

97.9 87 21 156/82 94 256

98.5 80 18 154/73 97 220

X X

This illstration shows how to correctly fill out a Medication Error Report. When you contact the nurse about the medication error she will instruct you to check the residents vital signs often. (Based on the med error she will tell you how often and how many time you will need to check the residents vitals.) You need to write those vital signs on this report and start a 48 Hour follow up and write the vitals on that form as well. 10

Section Two: Documentation

Documenting Medications
When medication is given it must be properly documented in the MAR and if it is a narc then it needs to be signed out in the narcotic Record Binder. If for some reason a pill wasnt given because the resident is LOA, refuses, or is unable to take medication it must be properly documented. This section coveres how to properly document medication.

Medication Administration Record (MAR):

The MAR Binder for each cart is located on top of the cart. Residents MAR are listed in alphabetical order by last name. A list of the PRN medication that a resident has been prescribed are listed first. However, if it is a new PRN order it may be found written among the scheduled pills. On the next MAR cycle it will be moved to the PRN section. After the PRN medications the scheduled medications are listed. They are listed by the date that they were prescribed or when the most recent change was made. Whether a medication is scheduled or PRN it must be signed out when it is given. If it is scheduled there will be a square (often called bubble) that corresponds to the date and time that a medication will be administered, you must initial this square. If the medication is a PRN, put your initials, write the time, and how many pills were given in the correct date column. Remember that this is a medical record and if you dont correctly document that a pill was given, then it wasnt given and that is a medication error. To see how to chart in the MAR see page 13 . If a pill is refused, spit out, or not taken for any reason; circle your initials and fill out the back of the MAR to explain why the medication wasnt given. Why it wasnt given, the time that it was supposed to be given, the time that you are recording this information and your signature.To see how to document medications on the back of the MAR, go to page 12. You will also need to record this information in the 24 Hour Report and Communication Book. To see how to chart the in the 24 hour Report and the Communication Book to go pages 16 and 17.

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Metformin 500 MG One Tablet Twice Daily

0800 RF

RF BT RF

BT BT RF BT RF AR

Medications

Cymbalta 75 MG One Tablet Daly

Scheduled Times

0800 RF

RJ ARRJ RJ ARAR RJ ARRJ RJ

RF BT RF

BTBT

RF BT RF

AR Med Tech Initals

0800 RF RF BT RF BTBT RF BT RF AR 1200 RF RF BT RF BT BT RF BT RF AR 1600 RJ AR RJ RJ AR AR RJ RJ AR RJ 2000 RJ AR RJ RJ AR AR RJ RJ AR RJ This illustration of a MAR front shows where the medication order is printed, where the times of the medication are listed, and the place that the med techs initial that they have given the medication. Ranitidine 25 MG One Tablet Four Daly

02/15/12

Ranitidine 25 MG

2000

Resident refused due to agitation

2100 A Rogers

This illustration shows how to correctly fill out the back of a MAR. When a medication is not given the back of the MAR must be filled out explaining why the medication wasnt given.

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Documenting Narcotics:
Narcotic Record:
Narcotics (narcs) are controlled substances and each pill or dose of a narc must be accounted for. When narc are received from a pharmacy they must be counted to verify that the correct number was delivered. If the number that was suppose to be delivered and the actual number delivered dont match the pharmacy needs to be contacted so that the correct amount of medication can be delivered. After the narcs are delivered and checked for accuracy, they need to be signed in on a Narcotic Record Sheet and added to the narc count and card count. The following steps show how to correctly sign in a narc: 1.On the top of the sheet there is a place for the residents name, the name of the medication, strength of the medication and the directions for administering the medication. Use the directions that are listed on the MAR, not the one listed on the card or bottle. If for some reason the order on the card or bottle doesnt match the one listed on the MAR notify the nurse, the order may have changed and we werent notified and need to obtain a current order so we can give the correct dose of a medication. 2. When signing in a narc the first line must be filled in with the date that you received the medication in the date column; the shift (AM or PM) should be filled out in the Time column; count should be written in the dosage column; your signature in administered by column; and the total number of pills or milliliters that were received in the # Remaining column. 3. When you give a narc you need to write the date that it was given in the date column; the exact time that you gave it in the Time column; for the dosage you need to write T for one tablet (if you are giving more than one tablet you need to fill out one line for each tablet that is given. Each line of the narc sheet represents ONE narc.); sign your first intial and last name in the adminstered by column and write how many are remaining in the # Remaining column.

Resident: Martha Jones Medication: Lortab

Narcotic Record
Strength: 5/500 mg

Dosage: 1-2 Tabs Q 4-6 hours PRN

date 2/20/2012 2/21/2012 2/21/2012 2/21/2012 2/21/2012 2/21/2012 Time PM 0800 1200 1200 1600 1600 dosage Count T T T T T Adminstered By ARogers RFielding RFielding RFielding RJames RJames # Remaining 30 29 28 27 26 25

This illstration shows how narc need to be signed in when they are recieved from the pharmacy; and how to sign them out when they are given. Remember, every line on the narc form rempersents ONE pill. If you give more than one pill at a time you need to sign each one out individualy. 13

Narcotic Card/ Narcotic Sheet Count:

To insure that all narcotics were correctly given and have been accounted for, med techs perform a narc count during each shift change. The med tech coming on duty will count all of the narc cards in the drawers and the med tech going off shift will count the narc sheets in the Narcotic Record Binder. These numbers MUST match eachother and MUST match the narc Card and Narc Sheet Count after the number of cards added and subtracted is figured into the count. This count must be done to insure narc cards and/or sheets havent been lost or stolen. If this count is off the nurse needs to be notified immediately so that the appropriate action can be taken. After this count, the med techs will then proceed to count the individual sheets and cards. This is done by the med tech coming on shift reading the number of narcs in the card or bottle and the name of the narc; and the other med tech will read the number on the sheet and the narc name. If the numbers do not match, the narc count is off and the med techs must figure out why before proceeding. If a narc is missing or was given to the wrong resident or at the wrong time the nurse must be notified immediately. If the narc was given to the wrong resident or at the wrong time a medication error has occurred and medication error procedures must be followed. (See Mediccation Errors pages 9 and 10) In this case the missing narc can be signed out specifying that it was given to the wrong resident or at the wrong time. If the narc is missing and can in no way be accounted for, a missing narcotic Form must be filled out by the med tech that lost the narc and the nurse must be notified immediately. She will decide whether the police need to be contacted to investigate the missing narc and if a drug test needs to be performed. She will then give instructions on how to proceed. To see how to fill out a missing Narcotic Form to go page 15.

date 2/20/2012

Shift PM AM AM/PM PM

Narcotic Card/ Narcotic Sheet Count

# of Cards 123 128 128 128 # of Narc Sheets 123 128 128 128 # Disposed Cards -5 0 0 -3 # Added Cards +10 0 0 -5

2/21/2012 2/21/2012

2/21/2012

Total at shift end 128 128 128 130

Med Tech/ Witness AR RJ RF BT RF RJ RJ AR

This illstration shows how to correctly fill out the Narcotic Card/Narcotic Sheet Count. This MUST be filled out everytime a shift change narc count takes place and must be signed by the med techs that participated in that count. This sheet should be filled out three times a day: Once when the AM med techs count together, once when the AM med tech counts with the PM med tech, and finally when the PM med techs count together at the end of their shift.

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Missing Narcotic
date Time Med Techs on Duty Name of Resident Narcotic belongs to Name of Narcotic Dosage of Narcotic Number of Narcotics missing
02/20/12 1400 Brynn Thomas and Rachel Fielding Martha Jones

Morphine

15 MG 1 Tablet

was missing from the card. We searched the med cart and med room, but were unable to find it.

Comments: When I was preforming NARC count with Riley James we noticed that one morphine tablet ____________________________________________________________ ____________________________________________________________
Signature of RN_____________________________________ Signature of Administrator____________________________ Date______________ Date______________

This illstration shows how to correctly fill out a Missing Narcotic form. Along with a description of the pill that is missing, the med tech needs to fill out a detailed description of what happend when the narc went missing. For example: was it dropped and you were unable to find it; did you notice that it was missing during a narc count? ou also need to describe what you did: Where did you look for it? who was Y there when the pill went missing or when it was noticed missing? 15

Documenting Residents Conditions

Daily Charting:
The med techs have two forms of charting that must be completed on each shift: The 24 Hour Report and the Communication Book. Both are important in documenting and communicating the occurrences of each shift. The 24 Hour Report is a condensed version of the daily charting. This sheet includes the name of each resident assigned to the cart whether the med tech handles that residents medication or not; and a place for each of the three shifts to chart anything that has happened during their shift. Things that should be charted on in the 24 Hour Report: Any medications that were ordered or delivered New or changed orders to medications If a medication wasnt given/taken and why A fall or other incidient 48 Hour Follow Up that was started, countined or completed PRN medications administered durning the shift, and what time they were given If the resident was transported to the hospital or was LOA for any reason (if the resident leaves on your shift for whatever reason and will be gone for a signficant amount of time chart where they went and if possible with whom).

Date:__________ Room 101 Resident martha Jones AM Shift 1 Lortab @ 0800 2 Lortab @ 1200 Reordered Lortab 102 Stan Walker Had a fall today, c/o back pain . Gave 2 Tylenol @ 1100. Resident Refused his 0800 Armour Thyroid . He stated that it makes him sick . I tried 3 times to give it. PM Shift 2 Lortab @ 1600 Lortab Delivered Graveyard

Still C/O back pain, gave 2 tylenol @ 1500 and 1700.

103

Marty Fenwick

Resident recieved the wrong dose of Lortab tonight. Vitals were taken and 48 hour follow up was started. Please monitor for any changes.

This illistration shows how to chart on the 24 Hour Report.

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 The other charting that must be completed during each shift is the Communication Book. In this book each resident has a sheet that the med tech must chart any changes in the residents status; if the resident fell you need to chart what happened as it written on the Incident Report; any PRN medications given and the result of the medication; and if the resident is LOA or was transported to the hospital. Communtication Sheets are part of the residents medical records. When you are charting only include objective information and leave out and subjective information. When a Communtication Sheet is full take it out of the binder, file it into the residents chart, and replace the old sheet with a new one. When you put a new sheet in the binder make sure that the residents full name is on both sides of the sheet. Because this is a medical record you need to write their full name, dont use a shortened version of their name or a nick name.

Martha Jones

101

2/2/12 2/2/12 2/3/12 2/3/12

Resident c/o not feeling well , aide took a tray for breakfast and Lunch_____________________________________________________________RF Resident Stated that she is feeling better. Came to lunch__________________RJ Resident c/o back pain at breakfast, I gave 1 Lortab at 0800. C/O pain again at lunch, I gave another lortab at 1200. Please monitor for any more c/o pain.__________________BT Resident had a fall when she was walking down to dinner, aides were able to help her up and she came to dinner. No apparent injuries, but she did c/o back pain and pain in her upper left leg. Please monitor

2/4/12 2/4/12

for changes._______________________________________________________AR Resident is still complaining of back and left leg pain. I gave 2 lortab at breakfast and lunch. I reordered lortab from the pharmacy,_______________________________BT Resident is still c/o pain in back and left leg, I gave her 2 lortab at 1600 and 2000. If pain continues family will take her to the doctor. Lortab was delivered tonight____RJ

This illistration shows how to chart in the communication book

17

Incident Reports:
An incident report is filled out to document falls, injuries, changes in a residents status, or altercations with other residents. A fall is defined as any contact with the ground that isnt intentional. If a resident is lowed to the floor by a staff member this still counts as a fall, and needs to be written up in an Incident Report. Injuries include: bruises, skin tears, scrapes, burns, etc. These also need to be documented with an Incident Report. Changes in a residents status include: change in vital signs, or behavior that isnt normal for that resident. All of these things can signify progression of a disease process, or medical problems that need to be addressed. That is why it is imperative that these incidents are properly documented. The other time that an Incident Report is to be filled out is when there is a physical altercation between two residents. If a physical altercation occurs between two residents, then the nurse needs to be notified immediately. The nurse will assess the situation and notify the appropriate people: the doctor, family, Adult Protective Services (APS), ect. The 48 Hour Follow Up accompains the Incident Report. The person that fills out the Incident Report will also need to fill out the description of what happened and the first line of vitals and resident condtion on the 48 Hour Follow Up. These two areas need to MATCH the information on the Incident Report. Both the Incident Report and the 48 Hour Follow Up need to be filled out in BLACK pen. It is the responsiblity of the med tech that recieves the Incident Report and the 48 Hour Follow Up, to check that they are filled out properly and the information that given is clear, concise and uses objective detail. If you receive an Incident Report or 48 Hour Follow Up that isnt filled out correctly, or is unclear, you will need to find the person that filled it out and have them fix any problems. To see how to correctly fill out an Incident Report and 48 Hour Follow Up go to pages 19 and 20.

18

1/6/12

Bruce Kendall

1000 Resident s Bathroom Normal , Alert and oriented

I walked in to the resident s room to give him his 1000 meds, and he was sitting on the floor of his bathroom. He stated that he tried to take himself to the bathroom and lost his balance and fell . He stated that his back hurt after he fell , but he had no other complaints of pain , and he had no apparent injuries. I helped him up and back into his chair and reminded him to page when he needs help.

No

Yes Yes

No

Dr. Shields Beth Potter, daughter

N/A N/A

No

N/A N/A

N/A N/A

1030 1030
N/A

C/O Lower Back Pain Alert and Oriented 97.5

1/6/12

65

18

145/75

I helped the resident up and to his chair. And reminded him to page for help.

Rachel Fielding

This illistration shows how to fill out an Incident Report. Remember that it needs to be filled out completely in black pen, with clear and concise details. If you receive an Incident Report that is not filled out properly it is you responsibility to find the person that filled it out and have them fix the problems.

19

Bruce Kendall

1/6/12

I walked in to the resident s room to give him his 1000 meds, and he was sitting on the floor of his bathroom. He stated that he tried to take himself to the bathroom and lost his balance and fell . He stated that his back hurt after he fell , but he had no other complaints of pain , and he had no apparent injuries. I helped him up and back into his chair and reminded him to page when he needs help.

1/6/12

1000

1/6/12 1800

1/7/12

0600

1/7/12

1030 2030

1/7/12

No apparent injuries, C/O lower back 65 97.5 pain . 18 140/75 63 98.5 Resident still C/O Lower back pain 18 137/68 70 No C/O Pain 98.2 20 158/80 79 No C/O Pain 99.0 20 148/81 79 Resident C/O of some back pain 98.9 20

145/75

R . Fielding MT R. James MT

S. Jenkins CNA B. Thomas MT

A. Rogers MT

This illistration shows how to fill out a 48 Hour Report. Remember that it needs to be filled out completely in black pen, with clear and concise details. If you receive a 48 Hour Report that is not filled out properly it is you responsibility to find the person that filled it out and have them fix the problems.

20

Taking and Recording Vital Signs:

Vitals are taken on each shift and must be recorded in the appropriate place. The four main vitals that are collected on each shift are the daily vitals the aides take, blood sugars, pulses or blood pressures that med techs must take before administering medication, and oxygen levels (O2).

Daily Vitals:

The aides are responsible for getting the daily vitals. When the med tech receives them, they need to be recorded in MAR. It is the aidess responsibility to collect the daily vitals that are on the daily vital sheet, and it is the med techs responsibility to make sure that vitals get done. Each shift has an assigned time that vitals must be completed by: AM vitals are to be done by 1000, PM vitals by 1600 and graveyard vitals by 0630. If the aides havent taken the vitals by these times, it is the responsibility of the med tech to remind the aides to get the vitals done. If the med techs have a problem with getting the daily vitals from the aides, then they need to notify the RCC so that she can correct the problem.

Daly Vitals in the MAR

Take BP Once a Day

0800

120 136 85 72

127 155 153 149 96 90 90 79

Med techs need to record the daily vitals that the aides collect every shift in the MARs.There are also vitals that the med techs are responsible to collect (it will specify in the MAR that the med tech need to take a vital sign), these vitals also need to be recorded in the MARs.

21

Blood Sugars:
Blood sugars are taken by the med techs on the AM and PM shift, on the graveyard shift one of the aides is assigned to take the blood sugars. Blood sugars that are taken need to be recorded in the blood Sugar binder found in the Med Room. Blood sugars are taken using either house supplies or the residents own supplies; it is the responsibility of the med tech to know which supplies to use when taking a residents blood sugar. When the house blood sugar strips are running low the med tech needs to notify the assistant administrator so she can order more. Because blood sugars vary according to the time of day, whether the resident has recently eaten, or taken a blood sugar medication (insulin or an oral agent); it is very important that blood sugars are taken at the assigned times. Doctors make changes to medication based on the blood sugars that are recorded. There is a big difference between a blood sugar of 97 before lunch and a 197 after lunch.

Resident:_Joan Murdock_____________
DATE
2/21/2012

Blood Sugar Log

PRE-LUNCH 250 315 104

Month/Year: Dec. 2011______

PRE-DINNER 200 249 300 BEDTIME 301 151 365

2/22/2012
2/24/2012

PRE-BREAKFAST 60 103 83

2/23/2012

70

179

128

253

This illstration shows how to fill out a blood sugar form. AM and PM med techs need to record the blood sugars that are scheduled on their shifts in the Blood Sugar Log. Graveyard blood sugars are collected by an aide on that shift and given to the AM med tech, it is the AM med techs responsiblity to record the graveyard blood sugars.

Oxygen Level (O2):

Oxygen level (O2) measures the percent of oxygen that the red blood cells are carrying in the body and is measured with an oximeter. Generally, residents that need their oxygen levels checked have it checked twice a day, once on AM and once on PM shift. Med techs take this vital and then record it in the MAR. (Most med techs take the oximeter with them on one of their pill passes and take the O2 during that pass.)

Take Oxygen Level Every Shift

0800

Some residents need their O2 taken, this is usually done twice a day (once a shift). After you have taken an O2 you need to record it in the MAR along with your intails. 22

95 95 93 98 2000 RJ AR RJ AR AR RJ 95 98 95 94 94 95
93 98

RF RF BT RF BT BT

Pulses and Blood Pressures:

There are some medications that require that a pulse or blood pressure be taken before the medication is administered. This is because the medication being administered causes a change in this vital sign. For example, digoxin controls the heart rate by lowering it, so before administering it an apical pulse must be taken. If the pulse is lower than 60 beats per minute the digoxen needs to be held. Giving it when the heart rate is lower than 60 beats per minute can cause an unsafe drop in heart rate. Reversely giving a medication that helps control low pulse or blood pressure when the vitals are above the approved level can cause an unsafe rise in the vital. MAke sure that you take the required vitals before giving a medication.

Pulse in Mar:

Digoxin 25 MCG 1 Tablet Every Day

0800 Pluse

RF RF BT RF BT BT 103 97 88 89 84 75

Some medication require that a pulse or blood pressure be taken before they are given.The MAR will specify which medications.These vitals are the med techs responsiblity to collect. After the vital is taken and the medication given the vital needs to be recorded in the MAR along with the med techs initals. If the vital is to low or high then the med tech needs to circle their initals and put an H under the vital to show that the medication was held because the vital was too low/high.

23

Using the Binders:

There are different binders that are used to file and store information on residents, new medication orders, medications that are delivered and reordered from the pharamacy. Each binder has different information stored in it and has a certain way that it is filed. This section offers a brief description of the binders that are used to store different medical information.

Communication Book:
This binder is where the current Communication Sheets for each resident are kept. In addition to the Communicaton Sheets, a copy of any new orders and instructions about a residents care. These copies are placed in front of the communiction sheet. Med techs need to read the Communication Sheets every shift so that they are aware of how each resident is doing. Copies of new orderes are put in this book for the same reason. As you read the Communication Sheets, you should also read the new orders, so you are aware of medication changes. Both carts have their own Communication Book and residents are divided into each book according if they live on the big cart side or small cart side of the building. Within each binder the residents are put in alphabetical order by last name. The Communication Books are kept with the corresponing med cart at all times.

New Orders Book:

The New Orders Book is kept in the Med Room. A copy of each new order that is received is placed into this binder for quick refernce. There is a tab divider for each letter of the alphabet and the new orders are filed under these tabs according to last name. When you file a new order in the book, go to the correct letter tab and place the order on the top of the other in that section. This way the most recent order is on top. If there is a question of a new order this book can be used as quick refernce instead of trying to find the order that may not yet be filed in the residents chart.

Reorder Book:
The Reorder Book is kept in the Med Room. This book is where the reorder sheets that are sent Superior are filed once they have been faxed to Superior. If there is a question about when something was ordered from Superior you can refer to the sheets that are in the book for a specific date. Also packaging slips that are sent from ALL pharmacies are filed in this book. This way we have record of the medication that is delivered from the pharmacies. The sheets in this book are filed in chronological order with the most recent sheets on top. After you have faxed a reorder sheet or received a packing slip from the pharmacy put that sheet on the top of all of the others in the book. That way the sheets stay in order.

Narc Hard Copy Book:

When a hard copy order for a narc is received from a docotor, you wil need call the pharmacy and let them know that we have a hard copy for a narc that needs to be picked up. The Narc Hard Copy Book is where those orders are stored until the pharmacy sends someone to pick them up. After you have called the pharmacy you will need to make an extra copy of the order and put it along with the hard copy into the book. When the driver from the pharmacy does come to pick up the hard copy, you need to have them sign and date the copy. This way we have a record of who took the order and when it is take, incase it is lost. 24

Blood Sugar Log:

Blood sugars are the only scheduled vitals that are not recorded in the MAR. They are recorded in the Blood Sugar Log. This binder is located in the med Room. Each resident, whose blood sugar we take, has a tab divider with their name on it. The Blood Sugar Log has enough space for one month of blood sugars. Once you have taken a blood sugar you need to record it in the appropriate palce. To see how to record a blood sugar see page 22. Once a Blood Sugar Log is full it needs to be placed in the RCCs box so that she can review it. After she has done this, the log needs to be filed in the residents chart under the Blood Sugar tab.

Medication Disposal Book:

The State requires that a record is kept for all of the destroyed medication. The Medication Disposal Book is where we keep our records. To destroy medication you will need a witness to verify that you have destroyed the medication. This is usually the other med tech or the nurse. If the medication is a narc, then the nurse must destroy the narc and you can act as the witness. When you destroy any medication you need to record that you did so in this book. On the Disposal Sheet in the book you need to write the date, the name of the resident that the medication belongs to, the medication name, the strength, the quanity of medication destroyed, the reason for destroying the medication (expired, the resident has passed away, ect.), and you and the witness will need to sign the the sheet.

The Supply Book:

The Supply Book is were all of the supplies given to the residents are recorded. The book has a sheet with every residents name and room number on it. These sheets are organized by room number. When you use first aid supplies, lab specimen supplies, or give residents supplies from the cages down stairs you need to record the supplies that you gave them the date that you gave them and sign that you gave them. This book is located by the phone in the Med Room.

25

Section Three: New Orders and Ordering From Pharmacies

New Orders:
New orders or changes to current orders are received almost daily. When a new order or a change to an existing order is received there are certain steps that must be followed to insure that the new order is documented properly, the medication is received from the pharmacy and is started in a timely manner.

Step One

Step Two

Step Three

When a new order is received it needs to be faxed to the appropriate pharmacies. If the resident receives medication from Superior then a copy of the order only needs to be sent to Superior. If the resident recevies meds from Mountain West, then a copy must be sent to Mountain West, and a copy that is marked as profile only needs to be sent to Superior. If a copy isnt sent to Superior then it wont appear on the next MAR. After the order has been sent to the pharmacy it needs to be stamped with the faxed stamp that is located by the fax machine in the med room. And then the date needs to be written next to the stamp. After the new order is faxed to the pharmacy, you need to make three copies of the order. One copy goes in the new Order binder in the med Room, one copy goes in the Communication book in front of the residents Communication Sheet, and the third copy goes in Assistant RCCs box in the med Room so that she can check the order on the next MAR. The last step is to give the original order to the nurse so that she can write it in the MAR. If the nurse isnt available then the assistant RCC will write it in the MAR. If she isnt available then the med tech can write the order in the MAR. To do this, call the on-call nurse that is on call and she will okay you to write in the order and tell you how it should appear on the MAR. Once the order has been written on the MAR, the order needs to be put in the nurses box in the med Room so she can note(sign) it. Once the nurse has noted the order it can be filed in the residents chart.

26

Ordering From The Pharmacy:

Currently there are two main pharmacies that supply the medication for Legacy House. They are Superior Care Pharmacy, which is the primary pharmacy, and Mountain West Apothecary, the secondary pharmacy. On occasion due to insurance issues a resident may need to go through another pharmacy, but this is rare, and on such occasions the pharmacy must be approved by the nurse because state regulations require that all medications be package in bubble packs. Medications need to be reordered when there is about seven days worth of medication left. This way if there is any problem with filling the prescription it can be resolved before the medication runs out. For every pharmacy, when you reorder a narc, you need to place a colored sticker next to the number on the narc card when you reordered it. You need to sign and date the sticker. This shows that the narc has been reordered. When the narc comes, place an X on the sticker. This shows that more narcs have arrived. Reordering needs to be done early in the day. If a PM med tech notices that a medicaion needs to be reordered after the pharmacy is closed, then that medication needs to be charted in the 24 Hour Report, so that the AM med tech can reorder it the next day. When a medication is delivered from a pharmacy only the med techs on duty can sign for that delivery. Before you can sign for medications you need to check the list that is sent with the delivery and make sure that everything that is in the bag and on the list match. If they dont you need to tell the driver and call the pharmacy immediately. Also if a pharmacy tries to send any medication in a bottle (liquid or pill form) then you need to refuse that medication and call the pharmacy immmediately and tell them that you can only accept medication in a med card or single dose syringes. The RCC needs to notified immedately with any problems when ordering medications; or if a pharmacy changes its ordering proceedures.

Superior Care Pharmacy:

Superior Care Pharmacy is the pharmacy that supplies the medications to the majority of the residents. They also print MAR for all of the residents regardless of the pharmacy that supplies a residents medication. Superior delivers scheduled medications in weekly increments; the packaging is referred to as auto med strips. Every week Superior faxes over a census form of the residents that they provide medications for, any residents that are LOA for any reason need to be marked off the census form so that Superior will not send an auto med that week for that resident. Auto med strips are delivered every Thursday evening and are put away on Thursday nights by the assistant RCC or med tech on duty. The new auto med begins on Friday with the 1700 dose. When these strips are delivered they need to be checked for accuracy. Any problems need to be reported to the pharmacy immediately so that the error can be corrected. Errors include: wrong medication or missing medication. Errors need to be reported to the RCC as well so that problems can be reported and corrected. Superior also delivers PRN medication, narcs, and various other medications such as Coumadin, antibiotics, and medications in medication cards. These medications have no set delivery schedule. When there is about a week left of the medication, it needs to be reordered. The med cards have a strip that can be pulled off and stuck to a reorder sheet that is faxed to the pharmacy. Any medications that dont have a strip that can be placed on the reorder sheet need to be phoned in to the pharmacy. Every shift should check the cart for any medications that are running low and need to be delivered. The reorder sheet for Superior needs to be sent in everyweek day before 1000. Any medications or new orders that are needed as soon as possible need to be calledin to the pharmacy, so that they know to send it out the same day. For example, when you receive a new order fax it to the pharmacy, and then call the pharmacy verify that they received the order, and tell them that it needs to be sent out same day. 27

Ordering Priority Medications:

When ordering a medication from Superior that are high priority, such as an antibiotic or Coumadin, the pharmacy needs to be notified that the medication needs to be sent priority. This can be done by faxing the order as normal, then calling Superior and telling them that the medication needs to come priority. The pharmacy then has four hours to deliver the medication. If you have any problems with the pharmacy when ordering priority medications notify the RCC so she can communicate these problems to the pharmacy.

Ordering After Hours:

If a medication needs to be ordered after hours or during the weekend call Superiors weekend number. An on call pharmacist will be paged and call the med tech back and then it will be decided how to best fill the prescription and have it delivered to Legacy House.

Mountian West Apothacary:

Mountain West Apothecary is the secondary pharmacy that is used. This pharmacy is generally used by residents that get the medications from another pharmacy, usually mail order or VA pharmacy. These medications need to be repackaged according to state regulations. Mountain West packages their medications into med bubbles, and delivers medication bubbles in a weekly increment. Also like Superior, Mountain West sends medication cards for PRN, narcs. The assistant RCC or PM med tech also changes out the med bubbles at night. And like the auto med strips, the bubbles need to be checked for accuracy. If there is an error then Mountain West needs to be contacted so the error can be corrected. Also if an order changes during the week Mountain West needs to be notified so that they can pick up the bubbles and correctly package them. Any medication that needs to be reordered from Mountain West needs to be phoned in by 1300. If the order is phoned in any later than 1300, it may not be delivered until the next day. The AM med tech needs to be aware of any medications needed and order them promptly so that they will be delivered when they are needed. Mountain West repackages medications that come from other pharmacies, such as the VA and mail order pharmacies. These medications are often delivered to Legacy House. When they are delivered, the med tech needs to call Mountain West and let them know what medications need to be picked up and repackaged. When the pharmacy comes and picks up medication they need to sign for the medication that they are picking up, so that there is a record of where medication has gone and who has taken it.

Other Pharmacies:
Hospice agencies provide any medications for their patients that relate to the admitting diagnosis and comfort medications. These medications are provided by a pharmacy that the hospice uses because hospice pays for them. Remember that hospice pharmacies will only send 14 days worth of medications and generally wont refill medications until a few days before they run out. To reorder medications that are provided by a hospice agency, call the agency or the residents hospice nurse and give a list of the medications that are needed. They will order the needed medication from the pharmacy, and the pharmacy will deliver. Some residents use other pharmacies for insurance reasons. When this happens and medications need to be reordered, call the pharmacy and give a list of the medications that are needed. The pharmacy will fill the medication and deliver it.

28

New Order Checklist

1. After receiving the order, fax it to Superior and any other pharmacy 2. Make 3 copies of the order: One copy goes the Communication Book One copy goes the New Order Book One copy goes in the Assitant RCCs box 3. Call the pharmacy and verify that they received the order, and ask them to send out the new medication. 4. Ask the RCC or Assitant RCC to write the new order in the MAR. 5. Put the orginal order in the resident chart or RCCs box(if not signed).

Reorder Checklist
Superior Care Pharmacy When possible pull off the reorder stickers and place on the reorder sheets that are faxed daily to Superior by 1000. Call in orders that dont have a sticker or new orders that need to be sent out. When a medication is need right away call it in and tell the pharmacy it is needed priority. Mountian West Apothacary Call in all reorders Hospice Pharmacies Call the hospice nurse for all reorders Remember that hospice pharmacies only send 14 days of medications.

Reorder all medications daily before 1300

29

Section Four: Emergency Situations

First Aid:
All aides that work for Legacy House are required to be first aid and CPR certified. However, when first aid needs to be administered, it is the responsibility of the med tech on duty to provide first aid. Part of providing first aid is to determine whether or not the injury can be attended to within the facility or if the resident needs to be sent to the hospital. Generally, med techs provide first aid for skin tears, cuts, less serious wounds, and small burns. First aid supplies are kept in the cupboards of the Med Room. Any supplies that are used need to be signed out in the binder that is kept in with the first aid supplies. To sign out supplies follow these steps: In the supply binder each residents name is on a piece of paper. These are organized according to room number. When a supply is used it, along with the date need to be written on the paper with the appropriate residents name and then the med tech needs to sign. Some supplies have stickers on them that say what they are. If the supplies have a sticker then place the sticker on the paper and initial and date next to the sticker. To read more about using the SupplyBook go to page 25. The supplies that Legacy House stocks are: band aides Bacatracin non adherent Pads Tegaderm Patches Gauze Squares If the injury that is being dressed is small enough that the tegaderm and pad can be cut down and still cover the wound than this can be done. Afterward, the extra supplies need to be labeled with the residents name and placed in their spot in the med cart for future use. Any injuries and first aide that is administered needs to be charted in the Communication Book and the 24 Hour Report, and an Incident Report and 48 Hour Follow Up need to be filled out. Also remind the next med tech to check any bandages that you put on a resident for excess bleeding/ discharge and cleaniness.

The picture to the left shows the supply cupboard in the med room where the first aid supplies are kept. The picture above shows some of the first aide suppies that we keep at Legacy House and the supply stickers that are used to sign out these supplies. 30

Transporting to the Hospital:

When there is a significant change in the residents status, serious illness or injury that cannot be handled with in the facility then it is necessary to transport the resident to the hospital. If the situation is an emergency then the ambulance needs to be called. If the change, illness or injury is non emergent then family needs to be contacted and asked whether or not they want the resident taken to the hospital via non emergent ambulance or if they prefer to take the resident to the hospital themselves. When sending a resident to the hospital two copies of the MAR, Face Sheet, PLOST form, and any other forms that are necessary (such as H &P) need to accompany the resident. One copy is for the EMTs and the other is for the hospital staff. When a resident is sent to the hospital the on-call nurse, administrator, and emergency contact must be notified that a resident has left the building. Also, if someone that was sent to the hospital returns, then the on-call nurse, administrator, and emergency contact need to be notified as well. However, if a resident has been in the hospital for more than three or more days, they may not return to the facility until the RCC or RN assesses the resident and clears them to come back. If for some reason the hospital tries to send a resident back that has been gone for three days and they have not been assessed; then the med tech needs to tell the hospital that the resident cannot return until assessed. And then the med tech needs to contact the on-call nurse so that appropriate action can be taken to readmit the resident. Once a resident returns from the hospital a 48 hour follow up needs to be started. See page 32 for a check list to send a resident to the hospital.

Employee Injury Procedure:

If an employee is injured on the job and the RCC or assistant administrator is not present then it is the med techs job to assist the employee in following the correct procedures. Procedure for an on the job injury are: 1. Call and report to assistant administrator/ supervisor 2. Fill out a Workmans Compensation Form located in the Wellness Center in the green binder 3. Fill out an Incident Report that includes: What happened When it happened How it happened What you did about it Vital signs of the employee The employee must go to First Med (Monday through Friday during regular business hours) located at 214 West 1500 South Bountiful, Utah. 801-295-6483. If the injury occurs on a Saturday, Sunday, Holiday, or after regular business hours the employee needs to go to InstaCare, located on Main Street. If the injury is serious and it is deemed appropriate to do so the employee should go to Lakeview Hospital. For Workers Comp to pay for any medical services provided for an on the job injury the employee MuST: Be seen within 24 hours of the injury Receive follow up instructions Go to any follow up appointments. If they fail do so, the Workers Comp claim will be denied and the employee will be responsible for the bill. Keep all of the paper work they receive and turn it in to his or her supervisor. The med tech that is assisting the employee needs to inform the employee about these rules. 31

Hospital Procedure
1. Assess the situation What is happening (Injury, Illness, Strange Behavior)? Can you idenfy any specific symptoms? Can this wait to be addressed by a doctor or by the nurse? (If youre not sure ask the nurse) 2. What are the residents vitals? Blood Pressure Pulse Temperature Resperations O2 Stat Blood Sugar Is a vital sign contrubing to this situation? (i.e. low/high blood sugar, low O2 Stat) 3. Is the situation emergent? Does the ambulance need to get here now? Or can a family member be contacted to transport to the hospital or Instacare? (If the family can not provide transportation, call for a nonemergent ambulance.) 4. Do you have the correct paperwork? Remember you need to make two copies of each Current MAR or Med List Facesheet PLOST Form 5. Have you contacted the correct people? (The building administrator, RCC and emergency contact person)

Calling the Ambulance:

When you call the ambulance you need to know a few things: 1. The Address: 79 East Center Street Bountiful and the residents room number 2. The med tech cell phone number you are calling from: Big Cart: (801)834-4261 Small Cart: (801)634-8267 3. The residents name, age and brief medical history 4. The reason that you are calling. (Injury, Illness, and any symptoms) 5. Vital signs that you have just taken.

Emergent Ambulance: 911 Non Emergent Ambulance: (801) 298-6000

32

Building Evacuation:
Whe the buidling needs to be evacuated, it is the responsibility of the med techs on-duty to supervise the evacuation and ensure that everyone and everything that is needed is evacuated safely. When the fire alarm sounds every employee in the building needs to go to the front desk to receive instructions on what to do. The alarm automatically notifies the fire department. If the med techs are the only supervisors present then they need to read the fire alarm panel to determine where the fire is. Once they have done this they need to send someone to investigate the area where the fire alarm has gone off. This person will report back if there is a fire or if something has tripped the alarm. When the alarm goes off regardless if it is a real fire or a false alarm the administrator and maintenance manager need to be notified. When the fire department arrives the firemen will need to speak with one of these managers. If for some reason neither of these managers can be reached then the assistant administrator can be contacted. If there is a fire or some other disaster that requires the building to be evacuated the staff will go to each room and notify each resident that the building needs to be evacuated. If the resident needs help because they are in a wheelchair, then the staff needs to help the resident into the wheelchair and escort the resident to the evacuation site. If the resident has a pet, the pet will need to be evacuated as well. If, due to the disaster a resident cannot be safely reached, do not attempt to do so, wait for the fire department to arrive and they will safely evacuate residents that the staff cannot safely evacuate. When evacuating the building all hallways must be cleared. Some of our residents leave jazzy wheelchairs in the hall way, and this is fine. However, in an evacuation situation these chairs and anything else that is in the hall way such as dcor needs to be moved in a residents room. The two other things that need to be evacuated are the residents charts located in the Wellness Center and the medication including MARS and Narc Records. When the evacuation of residents is safely under way the med techs are responsible to evacuate the med carts. The med carts can be loaded up with the necessary charting binders and any medications that are kept in the cupboards in the med Room and the Cottage Office. If for some reason the med carts cannot be evacuated then their contents need to be loaded into boxes so that the medications can be taken to the evacuation site. The evacuation site is the church across the street. If the building is open then the meeting site will be the gym. The Cottage residents will be evacuated to a smaller classroom to prevent them from wandering off. If the building is not open then the meeting place will be the church parking lot. Cottage residents and residents that live in the new addition need to be evacuated to the back of the building into the back parking lot. If it is safe to do so they can then be taken over to the church with the rest of the residents. This can be done by walking them around the block, if they are able, or using cars if possible. Once everyone and everything is evacuated a roll call needs to be taken of all of the residents and staff to insure that everyone is accounted for. Also, a make shift med area will be set up and the med techs and nurses will take account of the medication to insure that it is all accounted for. If the building cannot be reinhabited then all of the residents will need a place to stay. They can go with family, be sent to another facility or if necessary they will be put up in a hotel. No matter where the resident goes his or her medications need to go with them. The med techs will pull the appropriate amount of medication to be sent with a resident and sign out any pills that are sent. If residents are put up in a hotel, they will be there with other residents and staff will accompany them. In this case medications will not be sent ahead of time. They will be pulled as usual when they are scheduled to be given. A med tech and the appropriate number of aides will remain at the hotel at all times.

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Death Procedures:
When a resident passes away the appropriate people need to be notified. These people are the emergency contact of the resident, the nurse, and the administrator. If the resident is on hospice then the hospice nurse needs to be notified as well. If it is after hours, weekend, or holiday then the on-call hospice nurse needs to be called. Once the family has come in and asks, then the med tech can notify the funeral home. The funeral home is listed on the face sheet of the residents chart. If there isnt a funeral home listed then the med tech needs to ask the family what funeral home they would like to be contacted. If the resident is on hospice then hospice will call the funeral home, unless they ask the med tech to do so. Med techs, with the help of the aides, will need to perform post mortem care. This includes correctly positioning the limbs, changing the brief and clothes. If the resident is on hospice, hospice may elect to do this and may ask for the med tech or aides help in performing this care. Either way post mortem care needs to be performed in a timely manner before rigor mortis sets in. You will also need to fill out a Record of Death and have it signed by the mortician when they take the body.

BOUNTIFUL HOUSE ASSISTED LIVING RECORD OF DEATH

DATE OF ADMISSION: 3/4/2005 DATE OF DEATH: 11/15/2011 HOUR: 2145 ATTENDING PHYSICAN NOTIFIED: Dr. Geogre Gracia 801-555-1234 @2200 FAMILY NOTIFIED: Lisa Johnson, Daughter 801-555-2288 MORTICIAN NOTIFIED: Downunder Mortuary 801-555-3491 @ 2230 NAMES OF THOSE PRESENT AT THE TIME OF DEATH, AND THEIR RELATIONSHIP TO THE DECEASED: Lisa Johnson, Daughter, Justin Johnson, grandson and Hailey Johnson, granddaughter REMARKS: THE FOLLOWING PERSONAL ITEMS WERE TAKEN BY: ***************************************************************************** MORTICIANS REPORT RECEIVED FROM Brynn Thomas, Med Tech THE REMAINS OF: Martha Jones
RELEASE TO SIGNATURE EMPLOYEE SIGNATURE

NAME OF RESIDENT:Marth Jones D.O.B.: 2/3/1919 AGE: 91 SEX: Female

RACE: White

RELIGION: LDS

Room #: 361

DATE AND TIME

DATE AND TIME

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Section Five: Outside Agencies

In addition to the assistance that the resident receives from the staff of the Legacy House they may receive help form an outside agency. There are three outside agencies that provide assitance to our residents: Flex Care and home health or hospice (never both at the same time). It is not uncommon for a resident to transfer between home health and hospice. Nurses and med techs work closely with these agencies to insure that the resident is receiving appropriate care. For this reason, good communication is important. If a resident has a change in status, is LOA from the facility because they went to the hospital then the agency needs to be notified. Each resident on home health and hospice is assigned to a nurse; this is the person that needs to be notified about any changes or concerns about the resident. The resident and his or her family to decide on an agency. The nursing staff can offer recommendations but cannot tell the family which agencies can or cannot be used.

Home Health:
Home Health agencies provide skilled nursing cares that the staff of Legacy House cannot provide. These cares include diabetic care (admistering insulin), catheter care, physical therapy to build strength and balance, and wound care that requires a nurse to dress and clean wounds. If a resident qualifies to receive these cares from an agency, then they will also qualify for home health aide visits to help with ADLs. Each agency is different in the cares that they will provide for residents living in a facility. The agency along with the family and RCC will decide what cares the agency will help with. It is the responsiblity of the med techs and aides to know what cares a resident receives and on which days.

Hospice:
As a med tech you interact with each resident on a daily basis and will notice any changes in the residents status that may signify that the resident may qualify for hospice. When such changes are noticed the med tech needs to notify the RCC that the resident may qualify and benefit from hospice care. The RCC will contact the family and doctor to obtain the permission and order for an assessment to admit to hospice. Cares that hospice provides for a resident includes: weekly nursing visits to assess the residents status, skilled nursing cares, and aide visits for assistance of ADLs such as: eating, and bathing. Aide visits can be as frequent as the family, hospice nurse and RCC agree are necessary. Hospice will also provide any medications that relate to the residents admitting diagnosis, ekits and any other comfort medications not in the ekit. An example would be: if a resident was admitted to hospice for the progression of parkins disease, the hospice agency will provide any parkinsons medications such as carvadopa levodopa and comatin, medications such as lortab for pain management, and an ekit for comfort measures. Most of the medication that comes in an ekit will be in liquid form. These medications need to be in single dose syringes. When ordering liquid medication or an ekit from hospice make sure that you specify that liquid medications need to be in single dose syringes. It is the med techs responsibility to know what medications are provided by hospice and to reorder those medications from hospice. Reordering can be done by calling the residents 35

hospice nurse and telling him or her the medications are needed. The nurse will then call the pharmacy reorder the medication and have it delivered. Hospice also provides basic supplies such as chucks, briefs, and gloves. When it is necessary they will also provide hospital beds, wheelchairs, and walkers. Hospice is there to help the Legacy staff with the assistance that we need to give the resident the best quality of life. That is why its very important to communicate changes in condition and needs to the hospice. Appropriate times to call hospice would be: significant changes in the residents status, falls, injuries, if it appears that a resident would benefit from comfort medication, changing medication to help the residents status, reordering medications and supplies, and when the resident passes away. If the you arent sure whether or not to call the hospice nurse about something, it is better that you do call. Most nurses are appreciative of the extra information that you can share with them, especially since they are not with the resident on a day to day basis. And your observations may help in determining a better plan of care that will benefit the resident. In an emergency situation or serious injury of a hospice resident, the hospice nurse needs to be nofied and okay sending that resident to the hospital. Any resident that is on hospice and is sent to the hospital will automatically be discharged from hospice when they go to the hospital. Therefore, there needs to be a good reason that is approved by the hospice nurse.

Flex Care:
Flex care is a state agency that helps residents pay for the cost of living in our facility. Flex Care also provides many supplies for the residents that receive their services. If a resident is on Flex Care you can not give them Legacy House supplies. If they need more supplies then you need to contact Flex Care and tell them which resident needs supplies and what supplies are needed. When a resident on Flex Care has a fall or injury, or is transported to the hospital Flex Care needs to be notifed. A current list of residents on Flex Care is located in the front of both MARs.

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Section Seven: Caring For Residents with Diabetes and Dementia:

Residents with diabetes :
Many of the residents that live in the facility have diabetes. These residents generally require diabetic care from the facility, and often outside services such as home health. As med tech you are responsible to monitor blood sugars of diabetic residents, give medications that help control diabetes, and when necessary give a resident a prefilled syringe of insulin so that the resident can administer the insulin. It is important that blood sugars are taken at the appropriate times and recorded in the correct places (See Vitals on page 13-14). When a residents blood sugar is taken by a med tech and that resident is on home health, the blood sugar needs to be recorded in both the home health folder in the residents room and the blood Sugar Log in the med Room. Part of providing diabetic care is to beware of signs of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). If any resident displays signs of either of these conditions, then the residents blood sugar should be taken. An abnormal reading should be reported to the nurse immediately. If the resident is diabetic and on home health or hospice services then the agency should also be contacted immediately. The figure below shows the signs of hyperglycemia and hypoglycemia. Many of the signs of hyperglycemia and hypoglycemia are the same, so it important that you check the residents blood sugar before taking action.

Hyperglycemia Increased Thirst Headache Difficulty Concentrating Blurred Vision Frequent Urination Fatigue Blood Sugar over 180

Hypoglycemia Nausea Extreme Hunger Feeling Nervous or Jittery Cold Clammy Wet Skin Rapid Heartbeat Trembling Increased Confusion Anxiety Blurred Vision Headache Fatigue 37

Residents with dementia :

The Cottage is our Dementia unit. The residents in this unit need special care. Because of their disease, these residents often become memory agitated, aggressive, and are not able to verbalize complaints of pain, or of not feeling well. As a med tech, you need to be able to recognize signs of these things and help the resident. This can be done either by medication or redirection. Most of the Cottage residents have anti-anxiety medication that can be given when a resident is anxious, aggressive of agitated. Often, when a resident starts to show signs of any of these, redirection should be attempted first. This can be done by taking the residents attention away from what is causing them to feel the way that they do and providing them with another activity. If a redirection approach does not work, or if the residents state is bad enough that a redirection approach will not work, then an anti-anxiety medication needs to be given. If the resident doesnt have an anti-anxiety medication and it comes to the point that a one is needed then you need to notify the nurse. The nurse will contact the doctor and get a anti-anxiety medication. If the resident has a medication but it no longer works or it is diffucult to give by the prescribed route, you need to notify the nurse so that the dosage can be changed or another medication can be tried. An example would be, if a resident has lorazepam in pill form but when the resident is agitated he will not take the medication, then a liquid or cream form of the medication can be ordered. Often when you attempt to give a Cottage resident medication they will not take it. When this occurs you need to walk away and give the resident some time to calm down. Attempting redirection also helps to change the residents focus. After that you need to try a different approach to giving the medication. Different residents respond better to different approaches. Some residents have a hard time taking medication or take it better when it is crushed and in apple sauce. To do this, we must have signed order from the doctor. When you are giving medications, and notice that a resident is having a hard time taking medication or the resident would take medication better if it is crushed, then notify the nurse and she will get an order to crush the medication. Residents in the Cottage are often not able to complain of pain or illness. Often when a resident is in pain or ill they will become agitated. As a med tech you need to be able to read a residents body language such as: limping, favoring one limp over another; and facial expressions such as: grimacing, tension in the eyebrows to tell if they are in pain. When you notice signs that a resident is in pain, then you need to give them the proper medication. The med tech that is in the Cottage during the AM and PM shift acts as a third aide. As a third aide you need to help the Cottage aides care for the residents when they need help. As a med tech, you are also in the Cottage to observe the residents that are back there to better care for them. By consistently observing the residents, you will know when they need medication or redirection.

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Section Seven: Addtional Information

Supplies:
Legacy House has supplies that are available for residents to use. These supplies are briefs, chucks, and gloves. We need to charge for the supplies that are available. For this reason med techs are the only people that have access to the supplies. When a resident needs supplies then the aide will notify the med tech and it is then the med techs responsibility to get the supplies, sign them out and get them to the resident. Not all residents use the supplies that are provided by Legacy House, some are supplied by the family home health, hospice or Flex Care. It is the med techs responsibility to know whether or not house supplies can be given to a resident. Supplies are located in the basement in the storage room. They are kept in cages that are locked because they have to signed out and charged to a resident. The keys for the cages are located in the med Room. Supplies are signed out just like first aid supplies in the Supply binder.(See page 25) If a resident does not use our supplies, the med tech must notify the correct person so that supplies can be brought in.

Doctors Apointments:
Often med techs will need to schedule doctor or various other medical appointments. When you do this you need to know if the family will/can transport the resident to the appointment or if the Activities Department needs to transport. If Legacy House is transporting to an appointment then the appointment needs to be made on the days and during the times that the bus is available to transport. The times that the bus is available to transport is listed in the Med Room by the phone. After making the appointment, an appointment slip needs to be filled out. The med tech must record the following information on the slip: the residents name, room number, phone number, the date and time of the appointment, the doctors name and the address of the office, your name, and any notes that the activities person will need to know. Once the slip is filled out it needs to be placed in the activities managers box or given to her directly so that she can schedule transportation to the appointment. When a resident goes to the doctors appointment the med tech needs to copy a current med list (MAR), the Face Sheet, any other paper work requested by the doctor. Often the nurse will send a letter addressing the concerns that she has about the resident. This paper work needs to be given to the person taking the resident to the appointment, either family or the activities person.

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HIPAA:
HIPAA stands for the Health Insurance Portability and Accountability Act. This act insures the privacy of patients medical records and health plans provided by doctors, hospitals, and care facilities. It is the responsibility of all the employees of the facility to provide the privacy that HIPAA insures to our residents. Specifically for med techs, this means that you cannot disclose any medical information about a resident to anyone that the resident or POA of the resident has not okayed. Part of this includes having conversations about resident in public places, or with other residents or family members of other residents. As a med tech when you hear other employees discussing residents in this way you need to politely remind them that the discussion they are having is inappropriate because of the location or the person that they talking with. If a person asks about a resident and you cannot discuss that resident with them, politely tell them that you cannot discuss that information with them. If they have any questions or pressure you further you can refer them to the RCC, or building administrator. When a resident is transferred from the facility, employees are not allowed to discuss where that resident has gone and why with other residents or family members. If they pressure you refer them to the RCC or Building Administrator. As part of HIPAA, med techs need to destroy medication packets that have resident names, medication names, and doctor names on them. To do this shred bubble packs when they are empty and after passing medication shred the med strips. As well copies of new orders that do not end up in the charts need to be shredded when they are no longer needed. A good rule to follow is that anything that has personal information and does not end up in the residents chart must be shredded.

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Appendices
Appendix A: Common Narcs and Antibiotics Appendix B: Common Medications Appendix C: Symbols and Abbreviations Appendix D: Conversion Table Appendix E: Military Time Appendix F: Residents Charts Appendix G: How to Give a Nebulizer Appendix H: How to Give a Suppository

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Appendix A: Common Narcotics and Antibiotics

This is a list of the narcotics that are commonly used at Legacy House of Bountiful and the forms that they generally come in.
Medication Alprazolam (Xanax) Ambien Ativan (Lorazepam Darvocet Endocet Fentanyl Hydrocodone Lorazepam (Ativan) Lortab methadone Morphine Narco Oxycodone Oxycotin Percocet Tylenol 3 Valium Xanax Type Antianxiety Sleep Aid Antianxiety Pain Pain Pain Pain Antianxiety Pain Pain Pain Pain Pain Pain Pain Pain Pain Antianxiety Forms Pill, Liquid, and Cream Pill Pill, Liquid, and Cream Pill Pill Patch Pill and Liquid Pill, Liquid, and Cream Pill and Liquid Pill Pill, and Liquid Pill Pill Pill Pill Pill Pill Pill, Liquid, and Cream

This is a list of the antibiotics that are commonly used at Legacy House of Bountiful.
Antibiotic Amoxicillin Macrobid Prednisone Reflex Z Pack

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Appendix B: Common Medications:

This is a list of medicaiton that is commonly used at Legacy House of Bountiful, and what the medication treats. Medication Aricept Carvedilol Citalapram Counadin Cymbalta digoxin Ditalizem Flomax Furosemide Glipizide Haldol Lexapro Lisinopril metformin namenda Omperazole Senna Seroquel Simvastatin Trazadone Type dementia Heart Failure Depression blood Thinner Depression Heart Failure (Slows Heart Rate) High Blood Pressure Enlarged Prostate Water Pill and High Blood Pressures Diabetes Anxiety (Non Narcotic) Depression High Blood Pressure and Heart Failure Diabetes dementia Gastroesophageal Reflux disease (GERD) Constipation Bipolar and Schizophrenia Cholesterol Sleep Aide

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Appendix C: Symbols and Abbreviations:

Table 1:
This table lists the most commonly used symbols. These symbols are most commonly used on orders received from doctors, and on the MARs. However, they can be used when carting, if it is appropriate to do so. Symbol c c meaning before before meal Change Tablet Hour Wirh

Table 2:

This table list abbreviations that describe frequency. These abbreviations are most commonly used on orders received from doctors and on the MARs. However, they can be used when charting if it is appropriate to do so. Abbreviation Meaning Abbreviation bId PRN Q Qd QH QId TId meanining Twice a Day as needed Every Everyday Every Hour Four times a day Three times a day

Table 3:

This table lists common abbreviations that are used for specific medications. These abbreviations are most commonly used on orders received from doctors and on the MARs. However they may be used when charting if it is appropriate. Abbreviation ASA HCTZ K KCL MOM OTC PVN meaning Asprin Hydrochlorothiazide Potassium Potassium Chloride milk of magnesia Over the Counter Penicillin

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Table 4:

This table is a list of common abbreviations that are found on the MARs. Abbreviation ad AS OD OS OU PO PR R SOB SQ SUPP SUSP Tab TOP meaning Right Ear Left Ear Right Eye Left Eye Both Eyes By Mouth By Rectum Rectum Shortness of Breath Subcutaneous Suppositiory Suspension Tablet Topical

Table 5:

This table is a list of standard medical abbreviations that a med tech might encounter. Abbreviation bm b/o bP BS CHF c/o dm DNR DOB DVT DX FBS f/o H & P HR LOA N/A NKA meaning Bowl Movement Beacuse of blood Pressure Blood Sugar Congestive Heart Failure Complaint of Diabetes Mellitus Do Not Resuscitate date of birth Deep Vien Thrombosis diagnosis Fasting Blood Sugar Follow Up History and Physical Heart Rate Leave of Absence Not Available No Know Allergies

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Appedix D: Conversion Chart

Liquid (Fluid or Volume) Measurements Tablespoon Teaspoon 1/3 1 1 3 2 6 4 12 Fluid Ounce -1/2 1 2 milliliter* 5 15 30 59

*Milliliter and CC (Cubic Centimeters) are the same

Appedix E: Military Time:

All medications that appear in the MARs and when noting any time while charting needs to be done in military time. The table to the right gives the correct military hour for the time of day. Adding the minutes along with the correct military hour will give you the military time. For example if it is 1:25 pm, then in military time it is 1325. Civilian Time Militarty Time 1:00 am 0100 2:00 am 0200 3:00 am 0300 4:00 am 0400 5:00 am 0500 6:00 am 0600 7:00 am 0700 8:00 am 0800 9:00 am 0900 10:00 am 1000 11:00 am 1100 12:00 am 1200 1:00 pm 1300 2:00 pm 1400 3:00 pm 1500 4:00 pm 1600 5:00 pm 1700 6:00 pm 1800 7:00 pm 1900 8:00 pm 2000 9:00 pm 2100 10:00 pm 2200 11:00 pm 2300 12:00 am (midnight) 2400 48

Appendix F: Residents Charts

Med Techs are required to complete daily filing assigments. These assignments are posted in the Med Room and Cottage Office next to the resident charts. The big chart med tech is responsible to file all of the paper work in the Med Room and the small cart med tech is responsible to file the paperwork in the Cottage Office. The paperwork that needs to be filed is located in the file folders that is also located next to the charts. Here is list of tabs in the resident charts and the documents that are filed under those tabs. Inside Front Cover Hospice Evac/ Care Plan Service Plan Legacy Assessment Physicans Assessment Orders MARs Narcs Blood Sugars Legacy Services Outside Services Face Sheet, Flex Care Face Sheet, and the Pharmacy agreement The Hospice Evacuation Plan and The Service Plan for Hospice or Home Heath The Current Service Plan for Legacy House The Current Assessment and the First Assessment The Physicans Assessment Any signed orders from docotors, including RX Scripts, Signed Physican Requested Forms, Signed Med Lists and Orders From Hospice or Home Health Completed MARs Completed Narc Sheets Completed Blood Sugar Logs Any paper work received from Hospice or Home Health that is not an order, paper work from other facilities, or other agencies that have provided services to the resident. Completed Communication Sheets and 48 Hour Follow Ups Completed CNA Flow Sheets and Monthly Vital Sheets

nursing notes Progess notes

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Appendix G: How to Use a Nebulizer

The following instructions are general instructions on how to use a nebulizer. 1. Open the single dose vital of nebulizer solution and squeeze it in to the nebulizer cup. 2. Connect the mouth piece or mask to the T- shaped elbow, then connect the unit to the cup. This is gener ally done by twisting the cup and the unit together. 3. Connect the tubing to the bottom of the cup and to the port in on the nebulizer machine. 4. Turn the machine on and check for nebulizer mist. If there is no mist then something is not connected correctly, go back and check all of the connections. 5. To use a nebulizer sit in a comfortable upright position and hold the nebulizer in an upright position. 6. Place mouth piece between teeth and place lips around it. If using a mask make sure that it fits properly and that no mist is getting into the eyes. 7. Take slow deep breaths to insure that the medication is getting into the airways. 8. The nebulizer is done when the medication is gone from the cup, generally the machine will sputter when the medication is gone. 9. The cup and mouth piece need to be cleaned with warm water after each use to stop bacteria growth.

Image source: www.cfece.org/asthma This illstration shows the parts of a nebulizer.The mouthpiece is where the resident will place their mouth to inhale the medication.The mouthpiece is connceted to the T-piece. The T-piece is connected to the the dome.The Dome is where the liquid medication in turn into the vapor that is inhaled.The dome screws or snaps onto the cup.The cup is where the liquid medication is put. At the bottom of the cup is a place for the tubing to connect to the cup. and the tubing connects the nebulizer piece to the machine. Before you turn the nebulizer machine on, it is very important that you check all of the pieces and make sure that they are fasten tightly to each other. If they arent fasten tightly, the medication can leak out, or the liquid might not convert properly into varpor. After the resident is finished with the treatment, you need to disassemble the pieces and wash them to prevent bacteria growth.

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Appendix H: How to give a Suppository

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Wash your hands with soap and water. Put on gloves. Have the resident lie on his left side with their knees drawn up to his chest. Remove the suppository from the wrapper. Wet the suppository with warm water or put petroleum jelly lubricant on the suppository. This will make it easier to insert the suppository into the rectum. Spread the buttocks apart. Use your index finger to give the suppository. Gently put the suppository about one inch into the residents rectum. Hold the residents buttocks together for at least two minutes. This will keep him from pushing the suppository out. Wash your hands again. Once receiving the suppository, the resident needs to wait at least 30 minutes before going to the bathroom. This ensures that the suppository has melted and the medication has been absorbed.

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