Fy 15 Specialty Clinic Annual Education Policy/Procedure/Protocol Review

1. This facilities' organ procurment agency is:

Life Point

Death Star

SCOPA

LOPA

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Explanation

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

2. When is necessary to call Life Point? [CHECK ALL THAT APPLY]

For all discharges

Patients who death is imminent

Patients who are deceased

For all admissions

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Explanation

per CPM 00- 14 - 16, ORGAN AND TISSUE DONOR PROGRAM

Submit

3. How does one contact the Ethics Consultation Service? [CHECK ALL THAT APPLY]

Non-urgent consultation requests to the Ethics Consultation Service can be made by calling theEthics Consultation Service Hotline: 789-6910.

There is no ethics consultation service - don't call anyone - figure it out by yourself

PER CPM 00 - 14 - 25, INTEGRATED ETHICS, Attachment A

Explanation

PER CPM 00 - 14 - 25, INTEGRATED ETHICS, Attachment A

Submit

4. Here at the RHJ VAMC, a missing child alert is announced overhead as

Amber Alert

Ahsley Alert

Code Adam

Missing Child Alert

per CMP 07B-13-10, Missing Child Alert.
The Nationwide missing child alert. Only specially trained Charleston Police Department (CPD) officers can declare an AMBER ALERT.

Explanation

per CMP 07B-13-10, Missing Child Alert.
The Nationwide missing child alert. Only specially trained Charleston Police Department (CPD) officers can declare an AMBER ALERT.

5. Accordng to the RHJ VAMC's CMP for PROCEDURES FOR ACTIVE SHOOTER RESPONSE the employees' responsibilities include [CHECK ALL THAT APPLY]

Immediately calling extension 7251, 7268 or 7911 to report the incident

Immediately locking themselves in a secure room or evacuate if able to do so safely.

Remaining in a secure location until the “All Clear” is given by VA or local Police

Following all instruction given by VA Police or local Police

per CPM 07B-12-15, PROCEDURES FOR ACTIVE SHOOTER RESPONSE.

Explanation

per CPM 07B-12-15, PROCEDURES FOR ACTIVE SHOOTER RESPONSE.

Submit

6. According to the ORDERING AND REPORTING TEST RESULTS CPM, if the nurse takes a critical lab value from the lab, then the nurse will use what procedure?

Nurses never take critical lab reports

Put the Lab on HOLD until the MD can be tracked down and told personally

Write the lab value on a paper towel and tell the PCC to call the MD

per CPM 11-14-01, ORDERING AND REPORTING TEST RESULTS.

Explanation

per CPM 11-14-01, ORDERING AND REPORTING TEST RESULTS.

7. How should the nurse respond to VIEW ALERTS? [CHECK ALL THAT APPLY]

Ignore them - that's not my job

Acknowledge them by signing them

Sign them - even if it was sent erronously

What's view alert?

View Alerts are the responsibility of every employee of the Medical Center. All employees with a CPRS/Vista account must ensure alerts are resolved in a timely manner.
C. If View Alerts are erroneously sent to an employee an action is still required. Employees must contact the sender (previous signer) for explanation or forward to appropriate individual within 7 days of receipt.

Explanation

View Alerts are the responsibility of every employee of the Medical Center. All employees with a CPRS/Vista account must ensure alerts are resolved in a timely manner.
C. If View Alerts are erroneously sent to an employee an action is still required. Employees must contact the sender (previous signer) for explanation or forward to appropriate individual within 7 days of receipt.

Submit

8. Which of the following are considered to be "High Alert Medications"? (Select all that apply)

TPN

Heparin

Chemotherapy IV drugs

Insulin

Hypertensive drugs

CPM 110-21 High Alert Medications and Standardized Fusions. Located on the T drive--All CPMs--pharmacy. Type "medications" in the search box.

Explanation

CPM 110-21 High Alert Medications and Standardized Fusions. Located on the T drive--All CPMs--pharmacy. Type "medications" in the search box.

Submit

9. Veteran's state portable orders for "Do Not Resuscitate" (DNR) and /or other life sustaining treatment are recognized by this VA. TRUE / FALSE

True

False

per CMP 11-13-26, ADVANCE HEALTH CARE AND MENTAL HEALTH CARE PLANNING AND RESUSCITATION INSTRUCTIONS
Veteran’s state portable orders for “Do Not Resuscitate” (DNR) and /or other life sustaining treatment are recognized by VHA and authorized VHA practitioners. If the veteran has both an advance directive and state portable order which are inconsistent with one another, priority will be given to the most recent statement by the patient of his/her wishes. (Note: See VHA Handbook 1004.04 for more information specific to state portable orders.)

Explanation

per CMP 11-13-26, ADVANCE HEALTH CARE AND MENTAL HEALTH CARE PLANNING AND RESUSCITATION INSTRUCTIONS
Veteran’s state portable orders for “Do Not Resuscitate” (DNR) and /or other life sustaining treatment are recognized by VHA and authorized VHA practitioners. If the veteran has both an advance directive and state portable order which are inconsistent with one another, priority will be given to the most recent statement by the patient of his/her wishes. (Note: See VHA Handbook 1004.04 for more information specific to state portable orders.)

10. According to the CPM for ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT, this VA treats acute alleged sexual assaults. TRUE / FALSE

True

False

per CPM 11-14-40, ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT
Patients will be transferred for medical care and treatment and for forensic examination

Explanation

per CPM 11-14-40, ADULT VICTIMS OF ALLEGED ACUTE SEXUAL ASSAULT
Patients will be transferred for medical care and treatment and for forensic examination

11. Where does one find a list that will inform you of which MD has privileges for RHJ VAMC?

S drive

U drive

T drive

V drive

Located on the T drive under Priviledges-- Scopes of Practices

Explanation

Located on the T drive under Priviledges-- Scopes of Practices

12. Signs and symptoms of blood transfusion reaction include [CHECK ALL THAT APPLY]

Fever with or without chills

Tachycardia and/or tachypnea and dyspnea

Hives or rash to the patient's trunk and back

Sudden change in BP

Wheezing

Improvement of the hemoglobin and hematocrit values

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Explanation

per CPM 113-13-01, TRANSFUSION OF BLOOD COMPONENTS &
Mosby's nursing procedure Transfusion Reaction

Submit

13. The Laser Hazard Control Program states: (select all which apply)

All lasers/laser hazard areas will be labeled through appropriate signage to alert personnel of the presence of ongoing laser procedures

All laser incidents and near misses will be reported to the Laser Safety Officer and investigated.

Providers do not need Laser Privileges to use lasers.

Located on the T-drive CPM 0015FT-15-02 LASER HAZARD CONTROL PROGRAM

Explanation

Located on the T-drive CPM 0015FT-15-02 LASER HAZARD CONTROL PROGRAM

Submit

14. This is a latex free facility. TRUE / FALSE

True

False

per CPM 118-12-08, LATEX ALLERGY/SENSITIVITY

Explanation

per CPM 118-12-08, LATEX ALLERGY/SENSITIVITY

15. All vendors in the patient care environment must check in at the Information Desk in the Main Lobby.

True

False

Located on the T-drive CPM 118-14-30 VENDORS IN THE PERIOPERATIVE/PROCEDURE/PATIENT CARE ENVIRONMENT

Explanation

Located on the T-drive CPM 118-14-30 VENDORS IN THE PERIOPERATIVE/PROCEDURE/PATIENT CARE ENVIRONMENT

16. According to the CPM for ADULT/CHILD VICTIMS OF ALLEGED ABUSE, all suspected abuse must be acted upon. Who is the RHJ VAMC's designated reporter?

The MD

The RN

The Social Worker

The Case Manager

per CPM 122-13-02, ADULT/CHILD VICTIMS OF ALLEGED ABUSE
All professionals have a responsibility to act on all suspected abuse. A person, who, acting on good faith, in an emergency situation, reports or participates in an investigation resulting from a report, is immune from civil and criminal liability which may otherwise result by reason of this action.

Social Work Service has been designated as mandatory reporters for the Ralph H. Johnson VA Medical Center.

Explanation

per CPM 122-13-02, ADULT/CHILD VICTIMS OF ALLEGED ABUSE
All professionals have a responsibility to act on all suspected abuse. A person, who, acting on good faith, in an emergency situation, reports or participates in an investigation resulting from a report, is immune from civil and criminal liability which may otherwise result by reason of this action.

Social Work Service has been designated as mandatory reporters for the Ralph H. Johnson VA Medical Center.

17. According to the CPM, CONSERVATION OF MEDICAL CENTER LINENS, how can we ensure the control of linens within our areas to prevent pilferage, loss and misuse? [CHECK ALL THAT APPLY]

Linen carts should be covered at all times.

Do not wear patient clothing such as pajama tops, gowns or robes.

Do not use linens for anything else but paient care

per CPM, 137-12-03. CONSERVATION OF MEDICAL CENTER LINENS

Explanation

per CPM, 137-12-03. CONSERVATION OF MEDICAL CENTER LINENS

Submit

18. It is a policy at the medical center and selected CBOCs where Primary Care, Women's Health and/or Mental Health services are provided, access to clinically appropriate services that extend beyond regular business at least once on weekdays (Wednesday) and once every weekend (Saturday), at times and venues that match Veteran demand and expectation

True

False

Extended Hours Access for Veterans at Medical Centers and Selected Community Based Outpatient Clinics (CBOCs) CPM NO. 11-14-51

Explanation

Extended Hours Access for Veterans at Medical Centers and Selected Community Based Outpatient Clinics (CBOCs) CPM NO. 11-14-51

19. Requests for mammography studies will be processed by local Non-VA Care Coordination (NVCC) Team in coordination with the Women Veterans Program Manager.

True

False

CPM 114-14-04 Requests for Mammography Procedures located on the T-drive

Explanation

CPM 114-14-04 Requests for Mammography Procedures located on the T-drive

20. What values on the glucometer warrant immediate intervention?

200

400

300

400

Hypoglycemia-Hyperglycemia Protocol; This policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.

Explanation

Hypoglycemia-Hyperglycemia Protocol; This policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.

21. A SCI patient is at risk for Autonomic Dysreflexia if he/she has an injury at level ________ or higher?

T4

T5

T6

T7

CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidlelines. Type "spinal" in the search box.

Explanation

CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidlelines. Type "spinal" in the search box.

22. What would you do if your SCI patient was showing symptoms of autonomic dysreflexia?

A. Sit patient upright

B. Take patient's B/P

C. Seek to eliminate the cause

A, B, & C

Only A & C

CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidlelines. Type "spinal" in the search box.

Explanation

CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidlelines. Type "spinal" in the search box.

23. According to the CPM 136-02, who does one call to obtain assistance for a hard of hearing patient or a language interpreter?

AT&T Relay Service

TTY Phone

Bellsouth Relay Service

Both A & B

CPM NO. 136-12-02 Communication with Hearing Impaired /non-English Speaking Individual. located on the T drive--

Explanation

CPM NO. 136-12-02 Communication with Hearing Impaired /non-English Speaking Individual. located on the T drive--

24. Where does one find a list that will inform you of which MD has privileges for RHJ VAMC?

S drive

U drive

T drive

V drive

Located on the T drive under Priviledges-- Scopes of Practices

Explanation

Located on the T drive under Priviledges-- Scopes of Practices

25. When patients have missed multiple appointments the clinical scheduler is responsible for: (select all that apply)

Making no-show post card or patient cancellation letter when applicable

Calling the veteran to make an appointment without an identified immediate need.

Making sure providers adhere to policy

MANAGEMENT OF PATIENTS WITH MULTIPLE MISSED APPOINTMENTS
CENTER POLICY MEMORANDUM NO. 11-14-12 Located on the T-drive

Explanation

MANAGEMENT OF PATIENTS WITH MULTIPLE MISSED APPOINTMENTS
CENTER POLICY MEMORANDUM NO. 11-14-12 Located on the T-drive

Submit

26. Assigned staff who are trained in the use of digital imaging cameras are responsible for Dermatology Consult photographs.

True

False

Wound Documentation Through Photography
CENTER POLICY MEMORANDUM NO. 11-12-36 Located on the T-drive

Explanation

Wound Documentation Through Photography
CENTER POLICY MEMORANDUM NO. 11-12-36 Located on the T-drive

27. Reusable medical equipment (RME) has established policy for

All of the above

Use

Decontamination

Cleaning, reprocessing,disinfection, or sterilization

Non-Critical Reusable Medical Equipment (RME) Reprocessing CPM No. 002SPS-14-03, Use and Reprocessessing of reusable medical equipment (RME) CPM NO.002SPS-14-02 Located on the T-Drive

Explanation

Non-Critical Reusable Medical Equipment (RME) Reprocessing CPM No. 002SPS-14-03, Use and Reprocessessing of reusable medical equipment (RME) CPM NO.002SPS-14-02 Located on the T-Drive

28. Links to Material Safety Data Sheets (MSDS) for approved Non-critical reusable medical equipment cleaning agents can be found at the end of the policy on the T-drive.

True

False

The given statement is true because it states that links to Material Safety Data Sheets (MSDS) for approved Non-critical reusable medical equipment cleaning agents can be found at the end of the policy on the T-drive. This implies that the information regarding the safety data sheets for these cleaning agents is available and accessible through the T-drive.

Explanation

The given statement is true because it states that links to Material Safety Data Sheets (MSDS) for approved Non-critical reusable medical equipment cleaning agents can be found at the end of the policy on the T-drive. This implies that the information regarding the safety data sheets for these cleaning agents is available and accessible through the T-drive.

29. In order to help prevent and identify patients at risk for falling in the Specialty care area staff will (select all which apply)

Complete an annual fall screen and provide pamphlet explaining fall prevention in the home to patients at risk.

Implement interventions to create and maintain a safe patient environment

Implement universal fall precautions for all veterans

Assessment and Care of Patients/Residents at risk of Falling CPM NO. 118-13-13 Located on the T-drive

Explanation

Assessment and Care of Patients/Residents at risk of Falling CPM NO. 118-13-13 Located on the T-drive

Submit

30. The Specialty care nurse must use Hypoglycemia Protocol Note to document all BG results, treatments, and patient responses to treatment when hypoglycemia is identified in a patient.

True

False

Hypoglycemia-Hyperglycemia Protocol; This policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.

Explanation

Hypoglycemia-Hyperglycemia Protocol; This policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.

31. You can located nursings emergency plan on the T-Drive by selecting Service Policies, Nursing, then emergency procedures.

True

False

The correct answer is "True" because the statement provides clear instructions on how to locate the nursing emergency plan on the T-Drive. It states that by selecting "Service Policies," then "Nursing," and finally "emergency procedures," one can find the plan. Therefore, it is reasonable to conclude that the statement is true.

Explanation

The correct answer is "True" because the statement provides clear instructions on how to locate the nursing emergency plan on the T-Drive. It states that by selecting "Service Policies," then "Nursing," and finally "emergency procedures," one can find the plan. Therefore, it is reasonable to conclude that the statement is true.

32. Communication of patient diagnostic test results to patients should be:

A phone call from the clinician to the patient if test results indicate a need for timely intervention.

From any staff member available

From any member of PACT nursing team

Follow up for diagnostic porcedures Primary Care Service Line Memorandum 11C-10-01 Located on the T-drive

Explanation

Follow up for diagnostic porcedures Primary Care Service Line Memorandum 11C-10-01 Located on the T-drive

Submit

33. To improve the quality of life for Veterans RHJVAMC has establishing policies and procedures to effectively manage acute and chronic pain by using a stepped care model.

True

False

CPM NO. 112A-13-03 Pain Management Located on the T-drive

Explanation

CPM NO. 112A-13-03 Pain Management Located on the T-drive

34. Policy 00-14-16 Organ and Tissue Donor Program ensures that families of potential donors are presented with the option of organ and tissue donation in a manner which promotes informed consent in compliance with applicable laws and regulations while addressing the emotional/ spiritual needs of the family.

True

False

CPM 00-14-16 Organ and Tissue Donor Program located on the T-drive

Explanation

CPM 00-14-16 Organ and Tissue Donor Program located on the T-drive

35. The term "impaired professional" is used to describe the practitioner who is prevented by reason of illness, disorder, or other health/behavioral problems from performing professional duties at the expected level of skill and/or competence.

True

False

MEDICAL STAFF MEMBER HEALTH POLICY 11-14-04 Located on the T-drive

Explanation

MEDICAL STAFF MEMBER HEALTH POLICY 11-14-04 Located on the T-drive

36. Informed consent includes informing patient of : (select alll which apply)

Known side effects or consequences: predictable outcomes of a particular treatment or procedure; e.g., pain after surgery

Risks in a language understandable to the patient

11-12-09 Informed Consent Located on the T-drive

Explanation

11-12-09 Informed Consent Located on the T-drive

Submit

37. Medication labels should be prepared and applied at the time the medication or solution is prepared.

True

False

CPM 11-12-19 LABELING MEDICATIONS AND SOLUTIONS ON AND OFF THE STERILE FIELD Located on the T-drive

Explanation

CPM 11-12-19 LABELING MEDICATIONS AND SOLUTIONS ON AND OFF THE STERILE FIELD Located on the T-drive

38. Alerts not processed within 14 days will be automatically sent to the Service Chief or appropriate designee for timely processing

True

False

VIEW ALERT MANAGEMENT CPM 11-14-52 located on the T-drive

Explanation

VIEW ALERT MANAGEMENT CPM 11-14-52 located on the T-drive

39. It is VHA policy that all patients with potential for swallowing or feeding disorders must be appropriately assessed, referred for diagnostic evaluation (as necessary), treated, managed, monitored, and followed throughout the continuum of care.

True

False

CPM 112-11-07 MANAGEMENT OF PATIENTS WITH SWALLOWING (DYSPHAGIA) OR FEEDING DISORDERS

Explanation

CPM 112-11-07 MANAGEMENT OF PATIENTS WITH SWALLOWING (DYSPHAGIA) OR FEEDING DISORDERS

40. When a veteran/ caller is reporting suicidal or homicidal thoughts or other crises to the Ralph H. Johnson Department of Veterans Affairs Medical Center telephone operator or to other staff they should: (select all which apply)

NEVER PLACE A CALL ON HOLD

When possible make a warm transfer (allows for all three parties to be on the line at the same time)

CPM116-11-06 NTERVENTION FOR SUICIDAL/HOMICIDALPATIENTS VIA TELEPHONE Located on the T-drive

Explanation

CPM116-11-06 NTERVENTION FOR SUICIDAL/HOMICIDALPATIENTS VIA TELEPHONE Located on the T-drive

Submit

41. A large percentage of patient suicides occur within 3 months of discharge from acute inpatient care from previous suicide attempt.

True

False

CPM 116-13-05 SUICIDE ATTEMPTS: ASSESSMENT AND INTERVENTION PROTOCOL Located on the T-drive

Explanation

CPM 116-13-05 SUICIDE ATTEMPTS: ASSESSMENT AND INTERVENTION PROTOCOL Located on the T-drive

42. All professionals have a responsibility to act on all suspected abuse.

True

False

CPM 122-13-02 ADULT/CHILD VICTIMS OF ALLEGED ABUSE located on the T-drive

Explanation

CPM 122-13-02 ADULT/CHILD VICTIMS OF ALLEGED ABUSE located on the T-drive

43. What is this facility's (RHJ VAMC) emergency number?

5911

6911

7911

8911

ITD 11-14 Telephone Service Policy. Located in T drive--CPM--Master Index under Information Technology Division. Type "telephone" in search box.

Explanation

ITD 11-14 Telephone Service Policy. Located in T drive--CPM--Master Index under Information Technology Division. Type "telephone" in search box.

44. Patients are considered at-risk for harm if any of the following conditions exist, select all that apply:

Patient is legally committed

Patient has a court appointed legal guardian

Patient is considered dangerous to self or others

Have a physical impairment that increase their risk of harm to others

CPM 116-13-05 Suicude Attempts and Assessment. T- drive--All CPMs, type the word "suicide" in the search box

Explanation

CPM 116-13-05 Suicude Attempts and Assessment. T- drive--All CPMs, type the word "suicide" in the search box

Submit

45. Nursing practice will be provided using a systematic approach as outlined in the American Nurses' Association Standards of Nursing practice, Joint Commission Standards for Care of Patients and VA handbook 1180

True

False

Located on the T-drive 118-13-40 STANDARDS OF NURSING PRACTICE AND CARE

Explanation

Located on the T-drive 118-13-40 STANDARDS OF NURSING PRACTICE AND CARE