8/2021

Print Name: __________________________

Assigned Nursing Unit: _________________

Date:________________________________

PIH HEALTH HOSPITAL

WHITTIER, CALIFORNIA

EDUCATION DEPARTMENT

COMPETENCY ASSESSMENT:

GAIT BELT

Assessment Code: Method of Evaluation: 1 = Performs skill independently & completely D = Return Demonstration

2 = Performs skill but requires supervision O = Clinical Observation

3 = Can verbalize theory or how to perform skill, V = Verbal Feedback

but has had minimal opportunity to practice skill

PROCEDURE Assessment

Code

Evaluator

Initials

Method of

Evaluation Demonstrates proper application of gait belt

D O V

Verbalizes indications for use of gait belt

D O V

Demonstrates appropriate positioning and guarding techniques for

utilization of gait belt

D O V

Demonstrates the proper cleaning of the gait belt with the use of

antiseptic wipes

D O V

I acknowledge that I have read and completed the competency criteria support document.

____________________________ _________________________ ____________ Employee’s Signature Evaluator’s Signature / Initials Date

8/2021

Print Name: _______________________

Department: _______________________

Date: ____________________________

PIH HEALTH HOSPITAL

WHITTIER, CALIFORNIA

EDUCATION DEPARTMENT

COMPETENCY ASSESSMENT:

NOVA Blood Glucose Monitoring

Nova Glucometer Cleaning and Disinfecting

Assessment Code: Method of

Evaluation:________________

1 = Performs skill independently & completely D = Return Demonstration

2 = Performs skill but requires supervision O = Clinical Observation

3 = Can verbalize theory or how to perform skill, V = Verbal Feedback

but has had minimal opportunity to practice skill

PRE-ASSESSMENT Assessment

Code

Evaluator

Initials

Method of

Evaluation Checked Quality Control and battery status D O V

Performed quality control (if needed)

Verbalized policy on “dating” for all test strips, notes expiration

dates on control and strips.

Once opened, test strips are stable up to 6 months

D O V

D O V

D O V

ASSESSMENT and PLANNING Assessment

Code

Evaluator

Initials

Method of

Evaluation Reviewed physician’s order D O V

Explained procedure to patient D O V

Gathered needed supplies D O V

IMPLEMENTATION Assessment

Code

Evaluator

Initials

Method of

Evaluation Performed hand hygiene D O V

Donned on gloves D O V

Identified patient using 2 identifiers (name and MR#) D O V

Turned meter on D O V

Scanned operator ID badge or uses keypad to enter manually and

presses “Accept”

D O V

Selected “patient test” screen and presses “Accept” D O V

Scanned the strip lot number and “Accepts” if correct D O V

8/2021

IMPLEMENTATION (CONTINUED) Assessment

Code

Evaluator

Initials

Method of

Evaluation Scanned patient armband barcode by pressing the “Scan” key on the

screen bottom of the meter and scan the patient’s armband bar code.

If scanning fails, enters pt. account (visit) number manually. Presses

“Accept” when correct patient ID appears on the screen

D O V

Placed the test strip into the meter as shown on the screen D O V

Selected puncture site, cleanse site with alcohol wipe, allows to dry D O V

Punctured the fingertip of either the middle or ring finger, or infant

heel with lancet

D O V

Squeezed the finger to form a drop of blood. Wipes off the first drop

with a gauze

D O V

Placed a drop of blood on the test strip while the meter is in a

horizontal position

D O V

Applied gauze to skin to cover puncture site D O V

Viewed result on screen and “Accept” or “Reject” the result. The

result will appear in 6 seconds.

D O V

Removed test strip when analysis is complete and dispose of in

regular trash

D O V

Disposed Lancet in sharps container D O V

Verbalized patient testing process in isolation room D O V

EVALUATION, RECORD AND REPORT Assessment

Code

Evaluator

Initials

Method of

Evaluation Evaluated results and follows doctor order in coverage D O V

Documented results in eMAR D O V

Identified critical ranges and states corrective action by pressing

“Comment” key and choosing a comment that corresponds to

the patient’s current situation.

D O V

Followed nursing procedural protocol for hypoglycemic or

hyperglycemic follow up if needed

D O V

Documented date, time and person notified of the critical value D O V

Screened will display “Hi” for result over 600 mg/dL. Repeat test if

result does not correlate with patient medical condition.

D O V

QUALITY CONTROL TESTING Assessment

Code

Evaluator

Initials

Method of

Evaluation Pressed the QC soft key from the patient test screen

Performed high and low solutions every 24hrs or if meter is dropped

Once the high or low solutions are opened, the solutions are good for

3 months

D O V

D O V

D O V

Scanned the Strip Lot Number barcode

Pressed the “Scan” key

Pressed the “Accept” key if the lot number is correct

D O V

D O V

D O V

Scanned the QC lot number

Selected from the QC Lot List screen (press the List button) or

Scanned the barcode (press the Scan key)

Pressed the “Accept” key if the lot number is correct

D O V

D O V

D O V

Inserted test Strip in the test strip port D O V

QUALITY CONTROL TESTING (CONTINUED)

8/2021

Assessment

Code

Evaluator

Initials

Method of

Evaluation Mixed gently the Stat Strip Glucose Control Solution before each

use. Discard the first drop of control solution from the bottle to avoid

contamination.

D O V

Once the meter completed the test, the QC results will be displayed

along with a PASS or FAIL

To add a comment to the result, pressed the “Comment” key

To accept the result, pressed the “Accept” key

D O V

D O V

D O V

CLEANING

Assessment

Code

Evaluator

Initials

Method of

Evaluation Removed test strip from the meter D O V

Placed glucometer on a flat surface D O V

Donned gloves and removed a fresh germicidal wipe from the

canister

D O V

Wiped the external surface of the meter thoroughly with a fresh

germicidal disinfecting wipe

D O V

Wet contact time not needed on this step D O V

Discarded used wipe into an appropriate container D O V

DISINFECTING Assessment

Code

Evaluator

Initials

Method of

Evaluation

Used a new fresh germicidal wipe, thoroughly wiped the surface of

the meter (top, bottom, left, and right sides) a minimum of 3 times

horizontally followed by 3 times vertically avoiding the bar code

scanner and electrical connector

D O V

Wiped gently the surface area of the test strip port making sure that

no fluids enters the port

D O V

Do not allow liquid to enter the strip port connector or allow pooling

of liquid on the touch screen. If liquids does get into the strip port or

connector, immediately dry the components with a dry cloth or

gauze

D O V

Ensured the meter surface stayed wet for 2 minutes for purple top

and 4 minutes for orange top and is allowed to air dry

D O V

Discarded used wipe(s) and gloves into an appropriate container D O V

Performed hand hygiene and donned fresh gloves prior to testing on

the next patient if applicable

D O V

DOCKING D O V

Docked the meter in a Data Docking Station to automatically

upload stored meter data, download updated setup information,

and to charge meter battery.

D O V

I acknowledge that I have read & completed the competency criteria support document.

_____________________________ ____________________________________

Employee Signature Evaluator Signature/ Initials

8/2021

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8/2021

Print Name: __________________________

Assigned Nursing Unit: _________________

Date:________________________________

PIH HEALTH

WHITTIER, CALIFORNIA

EDUCATION DEPARTMENT

COMPETENCY ASSESSMENT:

MEDICATION ADMINISTRATION

Assessment Code: Method of Evaluation: 1 = Performs skill independently & completely D = Return Demonstration

2 = Performs skill but requires supervision O = Observation

3 = Can verbalize theory or how to perform skill, V = Verbal Feedback

but has had minimal opportunity to practice skill

KNOWLEDGE OF MEDICATIONS ADMINISTRATION

SKILLS, POLICY, AND PROCEDURE:

Assessment

Code

Evaluator

Initial

Method of

Evaluation Read policy# 87200.611 D O V

Utilized available resources to increase knowledge of medications as

necessary (PDR, pharmacist, lexicomp)

D O V

Identified potential interactions of medications and took appropriate

action

D O V

Titration orders must be clearly defined with the parameters of each

dosage adjustment D O V

All medications will be accurately and completely reconciled across the

continuum of care and performed upon admission to the hospital,

transfer within the hospital, discharge to home, discharge to TCU or

ARC, or external facility

D O V

Verbal orders are acceptable only during procedures or emergent

situations D O V

No medications may be left at the bedside except for Labor, Delivery,

and Maternal-Newborn. Topical items such as dermoplast spray, tucks

may be left at the bedside upon education to patient for proper use.

D O V

Reviewed procedure in the completion of Adverse Drug Reaction Form D O V

Medication errors will be reported to the ordering physician, and

pharmacy D O V

When transferring patients, all medications not contained in Omnicell,

including IV antibiotics and TPN will be placed in a tamper resistant

bag labeled with patient identification information for transport to new

location (excluding TCU, ARC, and Barlow)

Only RN can transport controlled medications

D O V

D O V

8/2021

Assessment

Code

Evaluator

Initial

Method of

Evaluation NON-FORMULARY /

PATIENT’S OWN MEDICATION (POM)

Non-formulary medications brought into the hospital by patients may be

utilized upon a physician’s order

The order must include the drug name, strength, frequency, and route of

administration

D O V

D O V

Non-formulary medications must then be sent to pharmacy in a tamper

resistant bag with print-out of Patient’s Own Medication (POM) report

in Order Reconciliation Manager (ORM)

Select the medications to be used during hospital stay

D O V

D O V

All medications identified by the pharmacy, will be placed in the

patient’s medication bin

All controlled substances will be locked up in the nursing narcotic

storage/Omnicell container

D O V

D O V

Medications: external & internal pumps

- External pumps will be verified for correct drug and

continuous/bolus dose at the bedside by the pharmacist and

will be entered as a “Non-formulary pump”

- Internal pumps can only be verified when the physicians

scans the pump for the dosing information. The patient may

continue using the pump. It will be entered as a “Non-

formulary pump”

D O V

D O V

Medications that were unable to be sent home will be sent and stored in

pharmacy in a tamper resistant bag with the POM report attached D O V

ADMINISTRATION OF MEDICATIONS Recognized priorities of medications: non-time critical versus time

critical

D O V

Calculated fractional doses of medications accurately, if indicated D O V

Verified medication being given matches with eMAR D O V

Checked medication expiration D O V

Inspected medication for particulates and discoloration D O V

Verified potential contraindication (Allergies, NPO status, procedures)

for prescribed medication

D O V

Opened and prepared all medications at the bedside D O V

Any injectable medication (IVP, IM subcutaneous, intradermal) will be

drawn up at the bedside regardless if they require reconstitution or

dilution

D O V

If medication is drawn up in a location other than the bedside, a label

containing the patient’s name, medical record number, name of

medication and dose will be attached

D O V

Accessed eMAR at patient’s bedside D O V

The patient’s ID band will be checked for patient name and medical

record number against the eMAR

Verbally validated patient name with patient or family when possible

D O V

D O V

Verified allergies in the medical record and patient’s wrist for a red

allergy band

D O V

Before giving medication, checked the 6 rights (right patient, right

route, right dosage, right drug, right time and right documentation)

If applicable, used institution bar code system to ensure medication

administration accuracy

D O V

D O V

8/2021

Assessment

Code

Evaluator

Initial

Method of

Evaluation Provides patient and/or family education regarding potential clinically

significant Adverse Reaction and side effects

D O V

Staff will remain in the room until all oral medications are taken D O V

Order replace dose through computer if needed D O V

No medications may be borrowed from another patient D O V

Medication that is dropped , contaminated, or partial dose is to be

disposed of in the pharmaceutical waste bin

D O V

PREPARING A MEDICATION FROM A VIAL

Perform hand hygiene

Prepared medication on a clean surface

Remove the cap covering the top of an unused vial to expose the rubber

seal

D O V

Disinfect vial by cleaning the access diaphragm using friction and a

sterile 70% isopropyl alcohol swab, allow to dry for at least 10 seconds)

D O V

Pick up the syringe and remove the needle cap or the cap covering the

needless vial access device.

D O V

Pull back on the plunger to draw a volume of air into the syringe

equivalent to the volume of medication to be aspirated from the vial

D O V

With the vial on a flat clean surface, firmly insert the tip of the needle or

needless vial access device through the center of the rubber seal

D O V

Inject air into the vials air space, holding on to the plunger D O V

Hold the vial with the non-dominant hand. Grasp the end of the syringe

barrel and plunger with the dominant hand to counteract pressure in the

vial

D O V

Keep the tip of the needle in the fluid while withdrawing the medication D O V

PREPARING MEDICATION FROM AN AMPULE

Perform hand hygiene D O V

Prepared medication on a clean surface D O V

Tap the top of the ampule lightly and quickly with a finger until fluid

moves from the neck of the ampule

D O V

Place a sterile gauze pad around the neck of the ampule. D O V

Holding the neck of the ampule with the gauze pad, snap the neck of the

ampule quickly an firmly outward away for the hands

D O V

Set ampule on clean flat surface D O V

Obtain the correct size syringe and a filter needle D O V

Withdraw medication by inverting the ampule and placing the filter

needle tip in the liquid without touching the rim of the ampule or by

tipping the ampule and placing the filter needle in the liquid without

touching the rim. Reposition the ampule so the needle tip remains in

the liquid

D O V

Draw up the medication quickly, keeping the needle tip under the

surface of the liquid

D O V

Tip the ampule to bring all fluid within reach of the needle. D O V

Carefully cover the needle with its safety sheath or cap. Engage the

sheath so it locks

D O V

Remove the filter needle and replace it with a needless access device or

appropriate size needle for injection utilizing a sterile technique

D O V

MEDICATION ADMINISTRATION ROUTES

PO D O V

Subcutaneous D O V

8/2021

IVP (refer to Medication tables if applicable) D O V

IVPB D O V

IM D O V

Z-track D O V

Sublingual D O V

Nasogastric D O V

Ophthalmic D O V

Rectal D O V

Vaginal D O V

Nasal D O V

Otic D O V

Nebulizer D O V

SPECIAL MEDICATION CIRCUMSTACES PATCHES

Labeled patches with date, time, and initials D O V

Documented site in the medical record D O V

Documented verification of patch placement in eMAR once a shift D O V

Patches with aluminized backing should be removed prior to an MRI

procedure refer to policy 87200.611

D O V

Demonstrated proper disposal of patches per policy D O V

ANTICOAGULANTS

Patients who have received spinal epidural should not receive

anticoagulants for 24 hours post operatively

D O V

While patient is on anticoagulants, bleeding precautions should be

maintained

D O V

Protime and INR verified prior to administering Coumadin at 1430

hours daily

D O V

PRN MEDICATIONS

Verified time of last dose D O V

DOCUMENTATION Documented all medications given on eMAR immediately D O V

Documented reason medications were not given (nausea, IV infiltration,

NPO, off the unit, refused)

D O V

Documented reason medications were given earlier or later than

scheduled administration time.

D O V

Demonstrated knowledge of procedure for narcotic waste D O V

8/2021

Assessment

Code

Evaluator

Initial

Method of

Evaluation PATIENT EDUCATION/DISCHARGE Reviewed medication reconciliation on discharge D O V

Instructed patient to take medication according to physician’s orders

utilizing age appropriate care with cultural considerations

D O V

All unused prescription and non-prescription medications must be

returned to the pharmacy when patient is discharged, including TCU,

ARC, and Barlow.

D O V

Inpatient bulk medications must be relabeled by the pharmacy and with

a physician order before releasing to the patient upon discharge

D O V

STORAGE/LABELING All medications will be stored in a specifically designated secured

medicine cupboard, closets, cabinet or storage room and accessible only

authorized personnel

D O V

Medication refrigerator must be kept between 36 and 46 degrees

Fahrenheit D O V

All opened multidose vials will have a vial label and dated to expire 28

days from the day it was opened D O V

Single dose vials will be discarded after prescribed dose has been given D O V

COMMENTS:

I acknowledge that I have read & completed the competency criteria support document.

I acknowledge that for any skill or competency that I did not receive a 1= (Performs skill

independently & completely), I was educated and agree on how to pull the policy, review

Mosby’s skills and seek a mentor before performing that skill independently.

____________________________________ ____________________________________

Signature Employee Evaluator Signature/Initial

8/2021

8/2021

PIH HEALTH HOSPITAL – ANSWER KEY

NOVA BLOOD GLUCOSE MONITORING QUIZ

Name:___________________________ School: _________________________ Date:___________

Circle the correct answer(s) 1. Once opened, the test strips are stable for up to ______ months. 2. What should you do if the meter scanner will not scan the patient’s armband barcode? a. Manually input patients 9 digit medical number b. Manually input patients 8 digit account number without leading zeros c. Manually input patients 12 digit account number d. Manually input patients 5 digit medical number without leading zeros 3. What should you do if quality control result falls outside the expected range? a. Press the “Comment” key and select the appropriate comments b. Repeat that level of control c. Put the meter back in the docking station d. A & B 4. Quality Control should be performed: a. Once a week b. Once every 24 hours c. If the meter was dropped d. B & C 5. What should you do if the patient result is critical? a. Press “Comment” to select appropriate action b. Turn off meter to avoid entering comment c. Repeat test if critical result does not correlate with patient medical condition d. A & C 6. If the meter displays “Hi” it indicates the patient result is greater than

a. The patients result is 600 mg/dL b. The patients result is 400mg/dL c. The patients result is 1000mg/dL

7. In order for the patient’s results to be captured and billed what must be done? a. Press the Accept key b. Nothing, it automatically gets downloaded c. Press the Continue key 8. Docking the meter: a. Uploads the data b Downloads information c. Charges battery d. All answers apply 9. To prevent contamination of glucometer a. Testing should be done at a horizontal angle b. Testing should be done at a vertical angle c. Testing should be done at any angle 10. If the back cover comes off the glucometer a. Tape cover back on glucometer and it will continue to work b. Call Bio Med c. Look at battery, if battery is expanded take to laboratory and exchange for new battery d. Take to laboratory and use a loaner

8/2021

11. Glucometer cleaning and disinfection is a 2 step process. To ensure proper disinfection, it is important to clean the meter prior to disinfecting the meter.

a. True b. False

12. The proper process for CLEANING the glucometer (Step 1) is as follows:

a. Don gloves, wipe the external surface of the meter thoroughly with a fresh germicidal

disinfecting wipe. Wet contact time is NOT needed for this step. Discard the used wipe into an

appropriate container.

b. Don gloves, wipe the external surface of the meter thoroughly with alcohol wipes. Wet contact

time is 4 minutes for this step. Discard the used wipe into an appropriate container.

c. Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting wipe. Wet

contact time is not needed for this step. Discard the used wipe into an appropriate container.

13. The proper process for DISINFECTING the glucometer (Step 2) is as follows: a. After CLEANING the glucometer, use a new, fresh germicidal wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port. Ensure the meter surface stays wet (2 minutes when using purple top wipes) and is allowed to air dry. b. Thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port. c. After CLEANING the glucometer, use a new, fresh germicidal wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 2 times horizontally followed by 2 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port.

14. What is the wet contact time for CLEANING and DISINFECTING the glucometer? a. There is a 2 minutes wet contact time for both cleaning and disinfecting

b. There is no wet contact time for cleaning. There is a wet contact time for disinfecting (2 minutes using purple top wipes and 4 minutes when using bleach wipes).

c. There is no wet contact time for both cleaning and disinfecting. 15. How many times must you wipe the glucometer when disinfecting (Step 2)?

a. Wipe the surface of the meter (top and bottom) a minimum of 2 times horizontally followed by 2 times vertically avoiding the bar code scanner and electrical connector. b. Wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 6 times horizontally followed by 6 times vertically avoiding the bar code scanner and electrical connector. c. Wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector.

16. Perform hand hygiene and don fresh gloves prior to testing each patient A. True B. False Score: ___/ 16 Answers are reviewed with student