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ESS Consultant Tech/LPN QI Audit Form
Facility:_______________________ Med Cart:__________________ Date:_____________
Consultant Tech/LPN:Katie Mullins
Information may be contained that is privileged, confidential, and exempt for disclosure under applicable law, and may include information utilized for Quality Assurance purposes.
Med Cart/PCC Match Back:
Resident Room Number Medication Order NO Stop Date In PCC NO Exp Date DC’d Med In PCC Missed Doc. In PCC Charted “9” In PCC Med on Cart NOT Match PCC Excess Supply on Cart Other Comments/ Correction Needed
Medication Cart Yes No N/A Comments
Are keys in possession of medication nurse? Is the medication cart locked? Is med cart clean and organized? Are all labels clean and legible? Are meds properly stored (not loose or unlabeled)? Are all medication boxes in date? Are all non-medication items (water/supplements/etc) dated? Are there NO outdated/discontinued floor stock? Were multi-dose vials/btls/inhalers dated when opened? Are old boxes being replaced with new boxes? Are medications separated by route of administration? Is applesauce or other soft food dated? Treatment Cart Yes No N/A Comments
Are keys in possession of treatment or charge nurse? Is a backup paper MAR available? Is treatment cart locked? Is treatment cart clean and organized? Are all labels clean and legible? Are all prescription treatments labeled for one resident? Are all prescription treatments within expiration date? Are all OTC treatments within expiration date? Are there NO discontinued treatments on the cart? Are "Order Change" stickers used where appropriate? Controlled Substances- Med CartsYes NON/AComments
Is cabinet/ drawer double-locked? Are only controlled substances present? Are there NO outdated/discontinued medications?
Facility:_______________________ Med Cart:__________________ Date:_____________
Consultant Tech/LPN:Katie Mullins
Information may be contained that is privileged, confidential, and exempt for disclosure under applicable law, and may include information utilized for Quality Assurance purposes.
Med Cart/PCC Match Back:
Resident Room Number Medication Order NO Stop Date In PCC NO Exp Date DC’d Med In PCC Missed Doc. In PCC Charted “9” In PCC Med on Cart NOT Match PCC Excess Supply on Cart Other Comments/ Correction Needed
Medication Cart Yes No N/A Comments
Are keys in possession of medication nurse? Is the medication cart locked? Is med cart clean and organized? Are all labels clean and legible? Are meds properly stored (not loose or unlabeled)? Are all medication boxes in date? Are all non-medication items (water/supplements/etc) dated? Are there NO outdated/discontinued floor stock? Were multi-dose vials/btls/inhalers dated when opened? Are old boxes being replaced with new boxes? Are medications separated by route of administration? Is applesauce or other soft food dated? Treatment Cart Yes No N/A Comments
Are keys in possession of treatment or charge nurse? Is a backup paper MAR available? Is treatment cart locked? Is treatment cart clean and organized? Are all labels clean and legible? Are all prescription treatments labeled for one resident? Are all prescription treatments within expiration date? Are all OTC treatments within expiration date? Are there NO discontinued treatments on the cart? Are "Order Change" stickers used where appropriate? Controlled Substances- Med CartsYes NON/AComments
Is cabinet/ drawer double-locked? Are only controlled substances present? Are there NO outdated/discontinued medications?