Boost Quality Assurance with QA Audit Forms

Get the most from your Quality Assurance department by using facility program audit forms.

An Admission Documentation audit is a fast and efficient way to make sure every essential assessment is completed and documented at admission.

A Facility Fall Prevention Program audit quickly assesses if your facility has everything in place to prevent and monitor resident falls and improve facility practices and procedures.

Keep track of unnecessary medications and adverse consequences with a Facility Medication audit.

Quality Assurance audit forms help the Director of Nursing and Administrator view the overall performance and consistency of facility practices and to pinpoint problematical areas of performance.

Debra Collins, RN, RAC-CT

As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term careand home health care federal regulatory changes.

She has written and published manuals for long term care and home health care documentation on nursing care plans, restorative nursing care plans,social service care plans, activities care plans, home health nursing care plans, home health nursing inservices, MDS 3.o forms for the MDS Coordinator, resources for theDirector of Nursing in long term care, nursing policy for long term care, long term care inservices, infection control for long term care, and Medicare/Medicaid documentation. The books are used by over one third of long term care facilities in the United States.

Debra has over 25 years experience in long term care and home health care. She worked as an MDS Consultant for many years, and is certified as a Resident Assessment Coordinator by AANAC, the American Association of Nurse Assessment Coordinators.

She is a member of the Bloomington Indiana Chamber of Commerce, National Nurses in Business Association, National Association for Female Executives, American Business Women’s Association, andLadies Who Launch.

Amazon Author Page Debra Collins, RN, RAC-CT

Good Nursing Policies and Procedures are the Blueprint for Quality Care

A long term care facility’s Nursing department policy and procedure manual should outline administrative policies and standards of care for basic nursing care procedures and all basic clinical practices.

It is the Director of Nursing’sresponsibility to review and update the manual at least annually to assure it is comprehensive and accurate. Updates must also be made when applicable due to changes in regulations or nursing standards of practice.

The master copy should be kept in the Director of Nursing’s office, and one copy placed at each nurses’ station so when policy or procedure is in doubt, staff can refer to the manual for clarity. To make it easier for staff to find subjects, it’s best if the manual includes a table of contents and an alphabetized cross-index.

The standard format for a procedure includes:

Statement giving objective goal of policy or procedure

Equipment and material needed

Staff the policy applies to, staff authorized to perform procedure

Documentation guidelines

Some facilities include in the policy and procedure manualmaster copies of long term care nursing forms. This helps to ensure uniform documentation throughout the facility.

Examples of policy and procedure manual topics:

Admissions and discharges

Blood sugar monitoring

Dressing changes

Feeding Tube

Isolation protocols

Lifts and transfers

Medication Errors

Post-fall protocol

Range of motion

Restraints

Standard precautions

Tracheostomy care

Urinary catheter insertion and care

Read more about topics of interest to the DON in long term care in the book Nursing Policy for Long Term Care and in the book  Director of Nursing Book .