New Communities RN Oversight Report – New Communities, Inc.

A. OBSERVE RESIDENTS’ SIGNS AND SYMPTOMS

(For item A, please refer to CL125F.3 RN Observation List for a list of resident concerns/items to be reviewed during your scheduled facility visit. The RN Observation List will be supplied by the facility supervisor and/or other designee.)

B,C,D Checkboxes

B. REVIEW RESIDENT RECORDS FOR COMPLETENESS AND ACCURACY
C. REVIEW THERAPEUTIC DIETS (Assisted Living Services only)
D. REVIEW MEDICATION RECORDS

(For items B, C and D please use and complete CL125F.2 RN Audit of Clinical Chart form for each resident record that is reviewed. Please attach all completed RN Audit of Clinical Chart forms to this document for submission).

Uploaded File

Names of all Resident clinical charts reviewed

E. REVIEW MEDICATION ADMINISTRATION PRACTICES AND PROCEDURES

Review the Medication Log Books:

(Ensure all scheduled medications (II-V) are being documented in the medication logbooks. Ensure CRMAs are documenting correctly and that the counts are accurate.)

Review the Medication Log Books: (Notes)

Review the MAR or, if using eMAR, review the “Progress Notes *New* Report” to:

Review the MAR or, if using eMAR, review the “Progress Notes *New* Report” to:

(Identify what PRNs are being given. Ensure CRMAs are documenting the reason why the medication was given and documenting the outcome.)

Review the MAR or, if using eMAR, review the “Progress Notes *New* Report” to: (Notes)

Review the PRN orders to:

Review the PRN orders to:

(Review PRN orders and ensure they all have the route listed and that they include the specific number of hours that is needed between doses vs. just listing BID or TID. Ex: allow 6 hours between doses.)

Review the PRN orders to: (Notes)

Review the MAR or, if using eMAR, review the Progress Notes *New* Report to:

Review the MAR or, if using eMAR, review the Progress Notes *New* Report to:

(Identify what medications, if any have not been administered during the time period between the last RN review. Identify with CRMAs why meds were not administered.)

Review the MAR or, if using eMAR, review the Progress Notes *New* Report to: (Notes)

Review vital signs:

Review vital signs:

(Review all blood pressures, weights and blood sugars a minimum of monthly or at least each visit if visit frequency is quarterly or less often.)

Review vital signs: (Notes)

Complete an audit of the medication fridge(s).

Complete an audit of the medication fridge(s).

(Ensure temperatures are below 41 degrees and fridges are clean inside and not being improperly used to store items other than medication (urine, food, etc.). Check insulin vials for replacement dates or insulin that is spoiled or damaged.

Complete an audit of the medication fridge(s). (Notes)

Medication Passes

Medication Passes

(If a need is observed by the RN and/or is requested by the program supervisor, review medication passes during your scheduled facility visit to ensure best practices are being followed and to assess CRMAs for accuracy and comprehension. RNs should reference the CL315 Administration of Medication policy for guidance on medication administration procedures.)

Names of CRMA(s) reviewed and RN observations/recommendations: