March 26, 2015Ashley Kish

ENVIRONMENT OF CARE RISK REDUCTION PROGRAM

identifies, evaluates and corrects physical plant issues (environmental threats) and unsafe practices that present an unacceptable risk to patients, staff, visitors and volunteers.

POLICY

The Safety Committee is charged with the responsibility of overseeing this program, and identifying and developing appropriate Plans of Action.

Using a 5-point scale, identifi es and rates all known environmental defi ciencies and problems determined to present a threat of physical injury to persons; damage to property or a threat to general safety.

Plans of Action to minimize and/or eliminate identifi ed risks are developed and implemented, as appropriate. When a risk poses an imminent threat to the safety or security of patients/staff, an

interim plan of action will be developed by program management and unit supervisors for immediate implementation.

The Safety Coordinator will document fi ndings, and keep written records of all completed assessments.

PROCEDURE

5 point scale

5 – highest risk; isolated area with incident history4 – high risk, non-isolated area with incident history3 – intermediate risk, no incident history, potential for harm2 – low risk, no incident history, supervised area1 – no risk, or such minor risk as not to be a serious consideration

RISK ASSESSMENT CRITERIA

Developed by the Safety Committee and outline the most effi cient and expedient course to be taken.

Developed following the criteria below:Problem identificationAnalyze cause of problemDevelop alternative solutionsRecommendation of plan of actionReview and Approval of plan of action Implementation and Monitoring of Results

Plans of Action are reported to Quality Council for review and approval, then to the Executive Policy Team for final review and approval.

PLANS OF ACTION

When staff become aware of a new unrecognized or unidentifi ed risk, it is their responsibility to immediately notify their supervisor/chain of command.

Supervisors are responsible for notifying the appropriate department to have the risk addressed (Health & Safety, Plant Operations , etc.)

An interim Plan of Action must be developed until the risk has been mitigated.

The priority for completing work orders is tied to the level of risk posed.

Every unit has been provided an Environment of Care Risk Reduction Manual, which is specifi c to that unit and should be readily available in the Nursing Station; The Environment of Care Risk Reduction Manual is not interchangeable between units.

REPORTING UNIDENTIFIED RISKS

Safety Alert Program Safety alerts with newly identified hazards will be emailed to all employees. Unit supervisors will print a copy of the safety alert to post in a conspicuous

location, thereby ensuring all staff has access to alerts. Safety alerts will also be shared at each inter-shift meeting with all staff. All alerts will include: photos and/or language describing the hazard and steps to

take to mitigate the hazard.

Training Conducted as part of New Employee Orientation Training on the Environmental Risk Assessment and Risk Reduction Program is

mandatory once a year as part of the Health and Safety Monthly worksite training for all staff Health and Safety will provide instructional cover letter to units with new identified risks to

include interim plan of action until risk is corrected. Program Management will ensure all staff is trained on the new risk and the interim plan

of action.

EDUCATION AND AWARENESS

POST TEST

REVIEW OF THERAPEUTIC DIETS

Therapeutic Diet – Any diet ordered for control or treatment of a medical condition.

Nutritional Management health maintenance/health promotion acute or chronic conditions allows us to determine whether a nutrition intervention/diet is working for the patient

WHY IS IT IMPORTANT TO FOLLOW DIETS?

REGULAR for patients without special nutritional needs or medical problems

2000/1800/1600 for patients in need of weight loss and/or weight management

CALORIE CONTROLLED DIETS

SOFT for patients with chewing

deficits secondary to poor dentation

GROUND for patients with swallowing

diffi culty, choking risk, progressing to regular diet

PUREE for patients with mechanical

deficits with chewing and/or swallowing

LABEL THESE CORRECTLY!

MODIFIED CONSISTENCY DIETS

VEGETARIAN excludes all meat, except fish and shellfish

VEGAN excludes all animal products, which includes meats, fish, shellfish, dairy, eggs

2 g SODIUM reduces the sodium content of tissues and prevents accumulation of excess fluid; may be

prescribed during renal disease, cirrhosis, hypertension, congestive heart failure

RENAL for patients with a need for increased protein, reduced sodium, potassium and phosphorus;

prescribed during end stage renal disease while undergoing dialysis. 2 g sodium ≠ renal

LABEL THESE CORRECTLY!

SPECIAL DIETS

QUESTIONS???