Write the unit name, date, and room numbers across the top line. Put the bed number or letter across the second line and sign it. Put a √ under the room number and bed beside all the tasks that need to be done. Write notes about special problems or add details in the Notes column.
| Unit | Date: | Room Number: | Notes: | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Signature: | Bed: | ||||||||||||||||
| 1. Paths | Remove unused equipment (canes/walkers). | ||||||||||||||||
| Instruct SW to ask family to remove unused items. | |||||||||||||||||
| If bedside commode is unused, ask staff to remove it. | |||||||||||||||||
| With resident's permission, rearrange room to clear paths. | |||||||||||||||||
| Instruct staff to keep paths clear. | |||||||||||||||||
| Instruct staff to keep overbed table across bed. | |||||||||||||||||
| Remove unused items from bathroom and store elsewhere. | |||||||||||||||||
| 2. Furniture | Instruct nursing staff and housekeepers to keep bed in locked position except during care or cleaning. | ||||||||||||||||
| Replace unstable bed with a stable one. | |||||||||||||||||
| Push bed to wall (check local and state fire codes). | |||||||||||||||||
| Remove all cardboard, lightweight, or unstable furniture. | |||||||||||||||||
| Instruct SW to ask family to remove or replace unstable items. | |||||||||||||||||
| 3. Easy Access | Arrange room so that items are within resident's reach. | ||||||||||||||||
| Instruct staff to keep items within arm's length of patient. | |||||||||||||||||
| Instruct staff to place cane, walker, or w/c within safe reach. | |||||||||||||||||
| 5. Floor | Instruct staff to wipe up all spills quickly. | ||||||||||||||||
| 7. Foot Care and Footwear | Ask nurse for podiatry consult. | ||||||||||||||||
| Instruct staff and resident to use specific shoes/slippers. | |||||||||||||||||
| Instruct staff and resident to use nonskid socks. | |||||||||||||||||
| Instruct SW to ask family to provide safe footwear. | |||||||||||||||||
