1. Metrics and Litigation Risk Compliance Presented by: Liz Metz, LVN- Regional QAC-QAAS

2. METRICS COMPLIANCE Q: Due Date: A: Due every 1 st Friday of the month. Q: How can we make DNS compliance with this Metrics log? Who can help DNS complete these information? A: Medical records can run KNS report for you on all *Pressure Ulcers and *Psychoactive meds. They can give you exact numbers from their monthly Incident report monitoring log *Falls and *Elopement. *Weights – RD or your Dietary Manager should have tracking for this area monthly. “ Make them accountable to give you these information monthly.”

3. Common Question regarding Accuracy of reports: 1. Psychoactive: numbers include all patients with Psychoactive meds for the WHOLE month, including Discharged patients. Not only the current patients at the end of the month. 2. Pressure ulcers need to include all NEW and WORSENED, Stage 2 to Stage 4 for the whole month census including discharged patients. 3. Falls – with major injury; bone fracture, joint disclocation, closed head injuries w/ altered consciousness, subdural hematoma.

4. Monthly Metrics submitted to NAHCI according to compliance: 1 st FAIRMONT: consistently every month and submitted timely from Jan-Dec 2013, Jan-Feb 2014. PERFECT!!! 2 nd COTTONWOOD: submitted timely from Jan-Nov 2013. Dec 2012-missed, Completed for Jan-Feb 2014. 3 rd UNIVERSITY: started on Aug., Sept., Oct., Nov.- missed, Dec. 2012. Completed for Jan. 2014, Feb – none.

5. 4th PACIFICA: started on Sept.-Dec.2013 (Nov and Dec were handwritten = percentile calculation were not totaled.) completed on Jan. 2014, Feb. 2014 – none yet. 5 th DANVILLE: started late on Oct 2012 but went back and calculated from Aug. 2012. Completed for Nov. and Dec. 2012 till Jan. 2014. Feb. 2014 – none yet. 6 th ROSEWOOD: started Aug.-Oct. 2013. None after. PETALUMA: Started Aug. – Oct. 2013. None after. 7 th WOODLAND: submitted for Mar. and Aug. 2013 only. None thereafter.

6. 8 th : APPLE VALLEY: Submitted on Aug. 2013, and none thereafter. 9 th : LINCOLN SQUARE, LINDA MAR, FAIRFIELD: None submitted for 2013 and 2014.

7. METRICS compliance

8. Litigation Risk Compliance “Also known as QAC audit tools” 1.Braden scale upon admit then wkly x 4

9. Litigation Risk Compliance 2. DNS Meet and Greet.

10. Anticoagulant and Diabetic Meds 1.No INR draw as prescribed on P.O. 2.Previous Coumadin dose given without communicating new INR results to MD or no response obtained yet from MD despite high INR result. 3.LN signing on incorrect days for specific dose of coumadin. (MWF vs TTHS different doses) 4.Med error on Insulin administration, not following sliding scale. 5.No areas for Insulin site and/or second LN initials on MAR.

11. Acute Transfer Documentation SKIN assessment not addressed upon transfer to acute. No reports communicated with ER Nurse and or f/u notes regarding patient disposition. IFTRF – not completed and not done at times when sending patient to acute. This a T22 regulation and not facility/nurses choice to complete or not to complete on reason for transfer. No discharge notes, or not addressing pertinent patient physical and psychological assessment. Bed hold and Physician orders not obtained upon or follow up.

12. Incident/Accident Documentation No care plans initiated on time of incident. Especially on skin issues. IDT notes not completed or done very late. Not communicated on 24H report, incident report not completed, Investigative report were not filled up at all. Nurses not addressing COC/incident within 72H. Insufficient documentation. Neuro check is not started, completed/ several holes noted. IDT notes do not specify effective intervention, Root cause analysis, total picture of patients declining condition. (i.e. multiple incident of same root cause.)

13. Appropriate Diagnosis for Antipsychotics F 329-Unnecessary medications – Without adequate indication Residents who have not used antipsychotic medications not given unless necessary. Diagnosis of DEMENTIA.

14. Behavior Monitoring F309-Monitoring should include resident’s target symptoms Must be specific based on observed behaviors of resident, must be measurable. Must match all areas: Consent, P.O., CP, Monthly Beh. Summary. Not for staff convenience.

15. Informed Consents were not signed No 2 nd signature and dates on verbal consents. Previously signed consents was obliterated with new increased dosage. Only exceptions to obtaining informed consents: Emergency situation Will be detrimental to resident to be fully informed.

16. Weekly Wound log Missing daily documentation on Pressure Ulcer stage 2 and up. Inaccurate information on site, measurement, intervention and documentations. – DNS how often do you check this log prior sending to corporate? Tx Nurses are not reporting non-pressure ulcers and no measurement. No report and/or very late on submission – DNS does your TX nurse informing you that she is not submitting report to corporate weekly? Wound log do not match Care plan and physician order on tx, dietary intervention and preventive interventions? Avoiding QAC when we ask to see the picture of the wound.

17. “We are here to identify issues that needed correction and improvement, to mitigate litigation. Please do not hide information from QAC’s.(QAAS) We are on the same fence with all of you and willing to help you. Just let us know how…” “ We thank you and appreciate all your cooperation and hard work.” THE END