Remain calm and continue normal duties. Notify all on-duty staff. Notify the Administrator or Asst. Admin, immediately. If neither is present. Med Tech on duty is the designee. If med tech is not available, the Lead Caregiver will be designated. Ask for a card or ID. Cooperate with inspectors and provide ONLY the requested information within your job role. Do not argue, become defensive, volunteer information, provide more than asked or speculate. Continue resident care unless directed otherwise.
Never guess or make up an answer. Politely state: 'I am not sure. Let me contact the Administrator, Asst Admin, or Person-In-Charge.' Notify management immediately.
A Med Tech should receive and verify medications. Confirm resident names, medication, quantities, and delivery paperwork. Narcotics remain secured until verified. Complete required signatures and store medications immediately. If after-hours, store medications in the med room and retain a copy of the delivery slip.
Stay with the resident. Do not move the resident unless immediate danger exists. Assess for injury, notify the Med Tech and Asst. Administrator or Person In Charge, if during the day. If during the overnight contact, Asst. Admin, if there is a serious injury to the resident. Call EMS if necessary, and complete the required documentation, the incident report.
Notify the Asst. Administrator or Person In Charge. Gather resident information, face sheet and Mar as directed. Document the transfer, update your census and notify the responsible party depending on time of day, according to facility procedures.
Notify the Med Tech immediately. Review discharge paperwork. Document medication changes and any new physician orders. Ensure new orders are communicated immediately to the pharmacy and the NP and documented. What is on the MAR must match what's in the Med Cart and vice versa. Failure to catch this will result in a fine.
Do not force medication. Encourage the resident and explain the importance of the medication. Notify the Med Tech and document the refusal according to policy. If the resident continuously refuses one or more of their medications, document it and request that the nurse practitioner have that medication discontinued and remove it from the MAR and cart.
Encourage participation and offer assistance. Document refusals. Notify the Med Tech, Asst. Admin or Administrator if refusals continue or affect the resident's health and safety.
Prioritize safety. Separate residents, if necessary, if it is safe and will not cause harm to yourself or the resident. Remain calm, avoid arguments, notify the Asst. Administrator or Person In Charge immediately, and complete an incident report. Contact EMS or law enforcement if safety is threatened. Do not hold back or restrain the resident at any time.
Immediately notify the Asst Administrator or Person In Charge. Search the building and surrounding grounds. Check sign-out logs and common areas. Follow elopement procedures and complete the required documentation, the incident report.
Remain professional. Listen respectfully. Notify the Administrator or AA and, if directed, document the complaint. Do not argue, make promises, become defensive, volunteer information, or speculate.
Do not release records. Refer all requests to the Administrator. Records may only be released through approved procedures and authorized individuals.
If a real fire or emergency exists, follow evacuation procedures and move residents to the designated area. Account for residents and await emergency personnel instructions. If a false alarm is suspected, notify the fire monitoring company and/or the fire department immediately. Contact management if the fire threat is real and follow facility procedures. Find the Fire monitoring number for your specific facility. It should be posted in a common area for easy access. When calling due to a false alarm that will not stop alerting, request that the system be taken offline for 8 hours until the issue is fixed.
Notify the Asst Administrator or Person In Charge immediately. Monitor residents and implement emergency procedures if the outage is prolonged and not due to a passing storm. During power outages, contact the fire monitoring company to prevent unnecessary fire department dispatches. Document actions taken.
Assess the area to verify there are no present dangers. Attempt to wake the resident and assess breathing and responsiveness. Call 911 immediately if appropriate. Verify the resident is not on the DNR list. Begin CPR if trained and required. Notify the Med Tech, Asst. Administrator and the responsible party according to policy. Complete the required documentation, the incident report.
16. Resident Leaving With Family, Overnight, Temporary Leave, or Discharge.
Verify the identity of the person picking up the resident using a valid photo ID and make a copy for the resident's chart. Document the departure date, time, destination, and expected return date if applicable. The Med Tech must prepare and review all medications being released, including any narcotics. Record all medications and quantities released on the Medication Release Form. The resident and/or responsible party receiving the medications must sign for receipt, and the Med Tech must also sign. No medications, including narcotics, may leave the facility without proper documentation, ID verification, medication inventory, and required signatures. If the resident is not returning, use the discharge form.
17. Missing Medication.
Immediately notify the Asst. Admin and Administrator. Verify that the medication was not recently administered, reordered, sent with the resident, or returned from the hospital. Check the delivery slip, medication cart, medication room, and resident medications. Do not substitute medications or skip required documentation. Contact the pharmacy if directed. Missing narcotics must be reported immediately to the Administrator and investigated according to facility policy. Complete all required documentation, the incident report.
18. Medication Destruction
Expired, discontinued, contaminated, or otherwise unusable medications must be removed from active inventory and secured until destruction. Do not let D/C medication accumulate. The Med Tech and Asst. Administrator may identify medications for destruction. The Med Tech and Asst. Administrator may destroy non-controlled medications with a witness; however, controlled substances (narcotics) may be destroyed only by an authorized licensed healthcare professional, in accordance with pharmacy requirements, with the Administrator and a witness present. Narcotics may not be destroyed by an Assistant Administrator, Med Tech, caregiver, or floor staff. All medication destruction must be documented on the Medication Destruction Log and retained in the facility's records. When possible, all medication should be returned to the dispensing pharmacy and documented with all required signatures.
19. What do I do if there is a Maintenance Issue / Broken Equipment?
If a maintenance issue, broken equipment, damaged furniture, plumbing problem, safety hazard, or building issue is identified, immediately enter the issue into the Maintenance Portal and notify the Assistant Administrator, or Person-In-Charge if resident safety is affected. Do not assume someone else has reported the issue. Emergency issues must be reported immediately through the Maintenance Portal. Document temporary corrective actions if implemented. Serious issues should be reported to the AA or Person In Charge by phone.
20. Unable To Report To Work / Running Late.
Staff must notify the Assistant Administrator or designated supervisor as soon as possible. Do not rely solely on group messages or notifications to coworkers. It is important to let your relief know; however, employees are responsible for ensuring management receives the notification. Failure to properly report an absence or tardiness may result in disciplinary action.