Description

This targeted chart audit tool bundle is designed to help skilled nursing facilities proactively identify, document, and address high-risk events or compliance concerns. Each audit in this series provides a structured, checklist-based approach aligned with CMS regulations and best practices, enabling your team to systematically review resident care, ensure regulatory compliance, and support quality improvement initiatives. Use this tool to detect gaps, prevent deficiencies, and demonstrate your facility’s commitment to resident safety and excellence in care.

• Abuse Case Review Audit Tool
  Focuses on identifying, documenting, and responding to suspected or confirmed cases of resident abuse. Ensures compliance with abuse prevention, recognition, and reporting requirements, and supports a safe, respectful environment for all residents
• Delay in Treatment Case Review Audit Tool
  Guides facilities in reviewing cases where there may have been a delay in recognizing or responding to a resident’s change in condition. Helps ensure timely interventions, proper documentation, and compliance with notification protocols
• Elopement Case Review Audit Tool
  Assists in evaluating incidents where a resident leaves the facility unsupervised. Supports risk assessment, prevention strategies, and regulatory reporting to protect vulnerable residents
• Failure to Honor Code Status Case Review Audit Tool
  Ensures that resident code status and advance directives are respected and properly documented. Reviews facility response to code status events and supports compliance with resident rights
• Falls Chart Review Audit Tool
  Provides a comprehensive checklist for reviewing resident falls, including risk factors, care planning, interventions, and post-fall follow-up. Supports fall prevention and regulatory compliance
• Injury of Unknown Origin Case Review Audit Tool
  Guides investigation and documentation of injuries with no known cause. Ensures thorough review, reporting, and compliance with abuse and neglect prevention standards
• Resident Adverse Outcome with Bedrails Case Review Audit Tool
  Focuses on incidents involving bedrails, including entrapment or injury. Supports safe use, documentation, and compliance with CMS and FDA guidelines
• Resident Choking Case Review Audit Tool
  Reviews choking incidents, including risk factors, dietary modifications, staff response, and follow-up. Promotes safe feeding practices and regulatory compliance
• Resident Exploitation Case Review Audit Tool
  Addresses cases of suspected or confirmed resident exploitation. Ensures proper investigation, reporting, and protection of resident rights and assets
• Resident Fall Case Review Audit Tool
  Similar to the Falls Chart Review, this tool provides a detailed framework for reviewing individual fall incidents, care planning, and corrective actions
• Resident Fall Case Review Reformatted
  Offers an alternative format for reviewing fall incidents, focusing on documentation, interventions, and regulatory requirements
• Resident Misappropriation Case Review Audit Tool
  Focuses on cases involving suspected or confirmed misappropriation of resident property or funds. Ensures thorough investigation, documentation, and reporting
• Resident Neglect Case Review Audit Tool
  Guides the review of suspected or confirmed neglect, including investigation, documentation, and corrective action to protect resident welfare
• Resident on Resident Altercation Case Review Audit Tool
  Reviews incidents of resident-to-resident aggression or altercations. Supports investigation, documentation, and interventions to prevent recurrence
• Self-Harm Attempted Suicide Case Review Audit Tool
  Provides a structured approach to reviewing incidents of self-harm or suicide attempts, including risk assessment, intervention, and follow-up care
• Significant Medication Error Case Review Audit Tool
  Reviews medication errors, including causes, interventions, and reporting. Supports safe medication practices and regulatory compliance
• Significant Weight Change Case Review Audit Tool
  Focuses on identifying and responding to significant weight changes in residents. Ensures timely intervention, documentation, and compliance with nutritional care standards
• Unsuspected Death Case Review Audit Tool
  Guides the review of unexpected resident deaths, including investigation, documentation, and compliance with notification and reporting requirements