Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

MED PASS TECHNIQUE
Resident Name/Room #:
Date:
LPN / QMA Name:
Schedule Pass Time: Actual Start Time: Stop Time:
INSTRUCTIONS: This tool may be used by an Administrator, Consultant, or Licensed Nurse to obtain information on types and
numbers if errors, and general adherence of staff to accepted policies and procedures and regulations. A mark is to be made in the
appropriate space at each occurrence of an error. The survey may be interrupted if there is an anticipated error that might endanger
the resident.
1.0 MED ADMIN
Resident Identified
Dose administered
Authorized doze
Correct dose time
Correct route or form of dose
Correct strength of dose
Correct drug
Right resident
2.0 TECHNIQUE
Hand washing before starting / between patients
Checks medication with order
Checks pulse or BP as required before administering
Omits medication when indicated per M.D. order
Correct handling of medication
Medication ingestion observed
Bedside medication checked
Prepares site properly
Cart cleaned properly
3.0 PREPARATION AND CHARTING
Dose preparation
Dose measurements
Crushing tablets or emptying capsules
Proper dilution
Charts immediately after administering
PRN reason and result charted
Prepouring
4.0 OTHER
Security of cart and med room
Efficiency
Resident needs are met
Handles interruptions appropriately
Infection control / aseptic technique correct
Comments:
MET
NOT MET
NOTE: The medication pass survey criteria should be used as needed to assist in conducting a med pass survey.
Name of Observer:
5.77