debriefing completed within 24 hrs of coercive event 15 n/a 100% STRATEGIC PERFORMANCE EXCELLENCE Nursing Department Initial Chart Compliance 2Q2016 - Lower Kennebec Findings Compliance Indicators 13 of 15 87% GAP note written in appropriate manner at least every 24 hours 15 of 15 100% STGs/ Interventions relate directly to content of GAP note. 2 of 15 13% Weekly Summary note completed. Diabetes education Teaching checklist shows documentation of patient 1 of 15 73% teaching (diabetic patients) 10 n/a Multidisciplinary Teaching checklist active being completed. 15 of 15 100% Dental education Teaching checklist 14 of 15 100% 1 ref. Nursing Assessment of Suicide risk completed with Treatment Plan 14 of 15 100% 1 loc. review Annual Assessment completed. 15 of 15 100% Patient’s rights signed. 6 of 15 60% 3 loc. Plan Reviewed/Modified Every 2 Weeks 14 of 15 93% Consent signed and 4 of 15 47% 3 loc. Interventions are clear, simple behavioral actions for nurses 15 of 15 100% for patient is behavioral and measurable 14 of 15 93% monitor sheets completed 14 n/a 93% debriefings completed w/in 24 hours after episodes of 1 of 15 93% HOH/SRC/Restraints 13 n/a meeting held 72 after coercive event 1 of 15 93% 13 n/a 13 n/a 87% plan updated after every coercive event debriefing completed within 24 hrs of coercive event 2 of 15 100% 13 n/a
debriefing completed within 24 hrs of coercive event 15 n/a 100% STRATEGIC PERFORMANCE EXCELLENCE Nursing Department Initial Chart Compliance 2Q2016 - Lower Kennebec Indicators Findings Compliance GAP note written in appropriate manner at least every 24 hours 13 of 15 87% STGs/ Interventions relate directly to content of GAP note. 15 of 15 100% Weekly Summary note completed. 2 of 15 13% Diabetes education Teaching checklist shows documentation of patient teaching (diabetic patients) 1 of 15 10 n/a 73% Multidisciplinary Teaching checklist active being completed. 15 of 15 100% Dental education Teaching checklist 14 of 15 1 ref. 100% Nursing Assessment of Suicide risk completed with Treatment Plan review 14 of 15 1 loc. 100% Annual Assessment completed. 15 of 15 100% Patient’s rights signed. 6 of 15 3 loc. 60% Plan Reviewed/Modified Every 2 Weeks 14 of 15 93% Consent signed and 4 of 15 3 loc. 47% Interventions are clear, simple behavioral actions for nurses 15 of 15 100% for patient is behavioral and measurable 14 of 15 93% monitor sheets completed 14 n/a 93% debriefings completed w/in 24 hours after episodes of HOH/SRC/Restraints 1 of 15 13 n/a 93% meeting held 72 after coercive event 1 of 15 13 n/a 93% plan updated after every coercive event 13 n/a 87% debriefing completed within 24 hrs of coercive event 2 of 15 13 n/a 100%