1. Clinical Care Paths and Notification to Physicians
Welcome to the Change of Condition Workshop and what we are also going to refer to as Clinical Care Paths. We will also talk about the Change of Condition documentation as you know it now and some of the focus of the Situation (Presenting Problem) Background or the findings and the Assessment (your findings on examination/observation) and Recommendations/discussion of treatment with the physician, also known as (SBAR). We will discuss a modification of the SBAR that meets our needs in the skilled nursing facility with both RNs and LVNs who conduct resident evaluations and observations. SBAR is the change of condition resident evaluation/observations. We will focus not on the actual resident intervention but on the supporting documentation and the notification to the physician; having all the key information for the physician to make a decision about the best course of action for the resident. We will also focus along with the staff who provide the services that makes quality happen in a facility.
Another focus will be the activities carried out by the Health Information Management/Record Designees review of the records for standup and to bring that key information to the meeting. We cannot forget the standup reviews or however you handle that review. It is at this meeting the Adm., DNS and others can assign and/or take responsibility for follow up to assure that quality services that we are proud to say we provide.
CHANGE OF CONDITION
Clinical Care Paths and Notification to Physicians

2. Regulatory Requirements
Change of condition documentation is required by
Federal Regulation
State Regulation
Standards of Practice for communication with the physician and good quality of care in the facility
Federal regulations indicate the resident has the right to care and treatment at a level that supports the $$ received. This is what it is all about, services provided with quality. The regulations indicate that the physician shall be notified of changes in condition, so shall the resident/representatives be notified of the changes in condition, including when there are changes in medications. The state regulations also require that you notify the physician when there are changes in condition/medication, etc., that the CP be updated and services modified to meet the needs of the resident.
With that said; there is a need to focus on the quality of the observation and examination of the resident prior to the notification to the physician. We will refer to that as SBAR- Situation, Background, Assessment (evaluation/observation by the licensed nursing staff) and Recommendations; discussion with the physician re: options and the physicians directions for care and treatment, ordering of tests, treatment in the facility or transfer to the acute. We do not forget the notifications to the family and the resident re: the condition of the resident based on the requests and agreement of the resident.

3. Change of Condition
F-157 §483.10(b) The facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident’s legal representative or an interested family member when there is…
The Federal regulations are more generic in the comments re: change of condition than in the Title 22
Notify when there is
An accident resulting in injury or potential injury requiring MD intervention
A significant change in physical, mental or psychosocial status (i.e. deterioration in health)
A need to alter treatment

4. Change of Condition-2 Notify when there is
An accident resulting in injury or potential injury requiring MD intervention
A significant change in physical, mental or psychosocial status (i.e. deterioration in health)
A need to alter treatment

5. Change of Condition-3 Title XXII 72311(a)(2)
Nursing service shall notify the physician of
(B) Any sudden and or marked change in signs, symptoms or behavior exhibited by the patient
(C) Any unusual occurrence involving a patient
(D) Change in weight of 5 lbs. (or 5%) of more in 30 days*
*Unless something different is stipulated by the physician, weight trends identified must also be reported. Weight change documented (unplanned gain/loss of 5 lbs, 5%-30 days, 7.5%- 90 days, 10%-180 days).

6. Change of Condition-4 Title XXII 72311(a)(2)
(E) Any untoward response to a medication or treatment
(F) Any error in administration of a medication or treatment
(G) All attempts to notify physicians shall be noted in the patients record including the time, method of communication and the name of the person acknowledging contact

7. Change of Condition-5
The SBAR – Change of Condition process will be used for all Changes of Condition.
There is a Change of Condition form to be used (H.O. #1).
If the form does not accommodate the change of condition, document in the Nurse Progress Notes and use the same process to describe the condition change, i.e., Situation/Presenting Problem, Vital Signs

8. Change of Condition-6
Evaluate/observe the condition and document the findings and follow up with the physician; also provide all the required notifications.
We will review the form/format a little later.

9. Change of Condition Monitor
An integral part of
Daily Stand up will review residents w/ C of C
AKA “Continuous Quality Improvement Program”
Ensures prompt follow up and complete documentation for any change of condition including those identified by resident or family complaints or concerns
Identifies trends or problems for prompt attention and possible follow up by the CQI Committee and Risk Management Program
Not all complaints or concerns indicate a change of condition but some can be the precursor to the onset of an actual change of condition. We’ll talk more about monitoring systems for resident and family concerns later in the program.

10. SBAR
This is the reference to the evaluation/observation if the resident and the findings on that review.
What is the Situation or Presenting Problem
What are the Vital Signs and are these within normal limits? Be prepared to discuss these with the physician in ALL CASES when the physician is called.

11. SBAR-2
Determine the area that is presenting the primary problem for the resident; do not dismiss other body systems, observation/evaluate and identify those areas that need assessment for the presenting problem, i.e., Mental Status – this area may be relevant to any number of conditions i.e.,, UTI, Falls, etc.

12. SBAR-3 Consider if the condition is a Cardiovascular issue
Respiratory,
Gastrointestinal
Genitourinary
Possible Infection-Generalized
Skin Condition
Fall
Unplanned weight change, ….etc.

13. SBAR-4
While there may be other conditions, then focus on the use of the Nurse Notes and not the Change of Condition Form.
If resident is placed on Oral Antibiotics then use SNF form in addition to the Change of Condition format as you are doing now – aside from your Nurses Notes. Physician’s oral antibiotic Orders for the

14. Change of Condition – Fitting into the Big Picture
Quality Care & Review System

15. Acute Mental Status Care Path
When making an assessment of the Mental Status of the resident, consider that may affect many of the changes of conditions also for other areas besides Mental Status.

16. Acute Mental Status
Lets review the Care Path and the clinical decisions that are important for evaluation/observation and notification to the physician when it comes to Acute Mental Status and/or just the Mental Status and other conditions and how it may affect the other changes in condition. (H.O. #2)

17. Change of Condition FORM
Lets review H.O. #1 the form you will complete.

18. CONGESTIVE HEART FAILURE
Lets review the Care Path for Congestive Heart Failure (H.O. #2) symptoms and the clinical decisions that are important for evaluation/observation and notification to the physician.

19. Change of Condition FORM
Lets review H.O. #1 the form you will complete. – Check out the Cardiovascular and the Respiratory and the condition you are observing/evaluating

20. DEHYDRATION
Lets review the Care Path for Dehydration Failure (H.O. #3) symptoms and the clinical decisions that are important for evaluation/observation and notification to the physician. Note this gives you a clue of other areas you should evaluate/observe- i.e. Mental Status, Functional Status, Respiratory, GI and Skin

21. CHANGE OF CONDITION FORM
Lets review H.O. #2 the form you will complete. Check out the Dehydration, mental status, respiratory, gastrointestinal and skin. What are your findings on observation/examination. Document those findings before calling the physician.

22. FEVER
Review of the Care Path for Fever of undetermined origin (H.O. #3)
Evaluate the Mental Status, Functional Status, Respiratory, Gastrointestinal, Skin
Is there a change in ability to eat or drink?
New cough, lung sound changes, incontinence, pain, new skin condition.

23. CHANGE OF CONDITION FORM
Lets review H.O.#2 Change of Condition Form; note there is the place to document Fever and determine if it is above the normal. Dr. notification of the fever alone is not enough. Evaluate the other systems to determine if there are symptoms for any of these areas. Also, make added notes in the nurses notes if there is not enough space here or you have added information.

24. RESPIRATORY
Review of the Respiratory Infection Care Plan (H.O. #4) focuses on the following
Vital signs and the normal vs. abnormal.
Consider any recent lab. X-rays
Review results of the recent labs.-x-rays and the positive/negative findings
If Antibiotic. Remember to complete the Antibiotic sheet. H.O. #_______(trisha I have to give this to you, will fax to office)

25. URINARY TRACT INFECTION
Review of Urinary Tract Infection (H.O. #4)
Consider the Vital Signs; > temp. Glucose
Lab Testing and any urinalysis maybe already completed and the findings,
Look at recent blood counts, persistent nausea and vomiting, unstable VS
Dysuria, alone, Fever, frequency, urgency

26. Change of Condition Form
Review Change of Condition Form (H.O. #1)
Consider the Vital Signs and abnormal results
Mental Status
GI/Hydration GU
Skin
Falls, if there was also a fall.

27. Vital Signs and WHY??? Review H.O. #_____ Vital Signs
Review the Weight loss issues as well.

28. ?????? Signs and Symptoms A, B. C?? NURSE CONSULTANTS:::::::
DO YOU REALLY WANT TO MAKE THIS YOUR STANDARD??? REGARDING NOTIFICATIONS??
Risks????

29. CHANGE OF CONDITION FORM
Review Change of Condition Form
General Instructions
On change in Resident’s condition, the licensed nurse evaluates the situation, identifies presenting problems, gathers information on all applicable systems and reports key observational findings to physician.
The change of condition form is a brief description of the findings on identification of change in condition. The licensed nurse evaluates the situation/presenting problem, gathers the information on all applicable systems and reports key observational findings to the physician. It is important that the key clinical information is available and ready to be provided to the physician when they are contacted. All changes in condition are to be reported promptly to the physician.
You will complete each section following evaluation of the resident, i.e. if there is a System that on evaluation is normal and there are no abnormal signs or symptoms then you will check ( ) No Abnormal signs or symptoms.

30. Change of Condition Form
Mental Status
Cardiovascular
Respiratory
Gland
Gastrointestinal/Hydration
Genitourinary
Possible Infection, general

31. CHANGE OF CONDITION FORM-2
Skin
Falls
Unplanned Weight Change

32. CHANGE OF CONDITION FORM-3
BACKGROUND ABD REVIEW OF VITAL SIGNS AND FINDINGS
Document Review of Recent labs – consider the SBAR for the various conditions and the abnormal findings.
Identify any new medications recently ordered and has the change occurred since then???

33. CHANGE IN CONDITION
List any allergies as those need to be known to tell the Physician in case there are med. Orders
Identify the system review.
Physician’s Notification and response
Resident and Family, Resp. Rep. notified.
Add additional comments, date and sign

34. CHANGE OF CONDITION-2
If need additional space use the Nurses Notes, Enter, Date, Time. Continuation of Change of Condition for (specify)_______.
At any time if a nurses note is not complete before you start the C of C form, draw a diagonal line through the page. Write See C f C.

35. NO. AMERICAN. NURSE CONSULTANTS
NO. AMERICAN..NURSE CONSULTANTS. DO YOU WANT TO GO FURTHER WITH THE TRAINING OR STOP HERE???

36. CHANGE OF CONDIITON Review System
Used to identify
Problems
Concerns
Conditions
…where additional follow up, review or referral are needed or desired
A method of continuous quality care outcome review
Action/results oriented
The daily quality assurance is a way to identify problems, concerns, conditions where the facility staff need to spend more time in determining the needs of the individual. The Daily QA system sets the stage for quality care and follow up by the person/s responsible.

37. System Benefits Reduces duplication of efforts Focus on
Follow up tasks identified and assigned to staff with specified due dates
Focus on
Timely identification of deficiencies/problems
Prevention of repeat deficiencies/problems
Continued review of follow through until resolution so that nothing “falls through the cracks”

38. System Benefits-2 Utilizes time spent in daily stand up meeting to
Maximize results
Obtain quality outcomes
Promotes ID team involvement in
Problem identification
Problem solving

39. System Components Change of Condition Documentation
24 hour report/shift report
Incident reports
Reports of resident/family concerns/complaints
Change of condition monitor
Daily quality assurance review form (log)
Daily standup meeting

40. 24 Hour Report
Centralizes nursing communications on a shift by shift basis
Helps to ensure timely follow up from shift to shift or day to day
Usually the first documented indication of a new or impending problem or change of condition
Frequently the initial problem identifier that starts audit trail
Important source of information for the IDT as well as nursing

41. Incident Reports Another important part of the audit trail
Provides detailed information that must be carefully documented, reviewed and trended
Must be integrated into the QA process and risk management process ongoing
Daily review of reports to ensure quality outcomes and timely follow up

42. Resident/Family Concerns and Complaints
Frequently not picked up and processed in a methodical manner
An important source of information about the resident, impending or actual problems and changes of condition
Need to be identified and addressed by the IDT in a timely manner [develop your method that works for your facility]
Give some examples of ways to document the resident/family concerns/complaints.
Examples might include a note on the Nursing Station, a ticket given to the Charge Nurse, a method of telling/documenting to the Charge nurse. The issue is to get every little problem documented, addressed and follow up and communication of action to the resident/family. Follow up by “Social Services” – other staff. This is the first line of providing quality care/quality of life. One of the most important things you can do is to keep the resident and family informed of what happened about that complaint; a first line of good quality care and good defense.

43. Resident/Family Concerns and Complaints-2
IDT involvement and reporting is critical –
COMMUNICATE!
What system do you have in place to document concerns and complaints? Does it include follow up to resolution? Many of you have a grievance procedure but this is more than that; this is the “little incidental issues” these are those issues you think will never amount to anything and they probably want…but it is the first line of customer satisfaction. Do you care? Do you report back to the resident, family, ombudsman. This is your chance to shine and make it right.

44. Change of Condition Monitor Defined
Monitors information given in the 24 hour report, incident reports and telephone orders for completeness, accuracy and follow up
Identifies deficiencies or “loose ends” in change of condition documentation
Serves as a work-plan for making corrections, when possible and assigning additional follow up as needed
Briefly review what is a correctable vs. non correctable deficiency

45. Change of Condition Monitor Process
Review 24 hour report, incident reports and telephone orders that denote a change of condition
List all changes of condition on the monitor form
Complete daily prior to the standup meeting
What if you cannot complete all of the change of condition review prior to standup. If that ever is the case then review the incidents and accidents, the new medications starting with the most critical, i.e., antibiotics, new treatment, behavior management drug.

46. What May Indicate a Change of Condition?
Changes can be
Physical
Mental or psychosocial
Incidents/accidents
Change can be
Slow to develop and show subtle signs or
Develop rapidly with more obvious signs and symptoms

47. What May Indicate a Change of Condition?-2
When reviewing the 24 hr. Report look for
Reports to nursing by
Family
C.N.A.’S
R.N.A.’S
Ancillary services
…that something has occurred or is changing in the resident’s condition
Don’t overlook resident/family complaints

48. What May Indicate a Change of Condition?-3
New orders for
An antibiotic,
Treatment,
Physical or chemical restraint,
New support or assistive device,
Weight loss or gain,
X-rays and labs
All of these indicate that something has changed with the resident and that follow up is required.

49. What May Indicate a Change of Condition?-4
Changes in orders can also indicate a change of condition. For example:
Increase in dose of psychotropic medication
A change from one type of physical restraint to another type
A change in type of assistive device used to treat a condition or maintain mobility
Change in treatment order when a site is not responding or is worsening
Not only new orders indicate a change of condition. Sometimes the a change in an existing order can also signify that the resident’s condition is changing or deteriorating and subsequently, documentation of all follow up efforts is necessary.

50. What May Indicate a Change of Condition?-5
When reviewing incident reports look for
Falls
Medication errors
Injuries/death resulting from defective equipment
Resident to resident or resident to staff altercations
Allegations or suspected abuse
Elopement
Any of these conditions require documentation and follow up. Documentation must be factual and descriptive with subjective information documented as such. In these cases dates, times, witnesses, circumstances surrounding the incident or accident and the condition of the resident must all be documented from the time the incident was noted or occurred (which may not be the same time) up through resolution of the problem. Remember that in cases where another individual is involved the name of that individual is NOT included in the resident’s chart. Instead the staff position, like CNA, or resident’s roommate are used instead. This is a medico-legal as well as privacy issue.

51. What May Indicate a Change of Condition?-6
When reviewing the 24 hour report look for
Physical Changes
Cardiac distress
SOB
Chest pain
Pain or change in level of pain
Vision loss
Weakness
Abnormal, foul smelling drainage
Slurred speech
Loss of consciousness
Dizziness
Seizure activity
Bleeding
Lacerations or bruises
Nausea, vomiting
Abdominal distention
Change in fluid uptake
Change in mobility or ambulation
Elevated Temperature
This is far from an exhaustive list. This is just to give you some indication of the kind of things that may present themselves in a 24 hour report.

52. What May Indicate a Change of Condition?-7
When reviewing the 24 hour report look for
Changes or onset of Mental/Psychological Changes
Confusion
Depression
Behavioral outbursts (verbal or physical)
Danger to self or others
Onset of wandering
Memory loss
Suicidal thoughts or gestures
Aggressive behavior, striking out
Resists or refusal or care, med or treatment
Allegations of abuse or mistreatment
Hallucinations or delusions

53. Change of Condition versus Significant Change in Status
There are changes in the resident’s condition that may result in what the RAI manual calls a “Significant Change of Condition”. Why is this important to note?

54. The Clock is Ticking
You have 14 days to determine whether or not a change of condition falls into the category of significant change and would then require a significant change of condition RAI assessment, which resets the residents MDS/RAI cycle from that assessment forward. This is very important and noting subtle changes of condition…many times those reported by the resident or family, can be critical in making this determination and doing the assessment timely. Remember that change can be slow to develop and show subtle signs over time.

55. When a COC Is or Is Not a Significant Change in Status
Not self limiting
Impacts more than one area
Requires ID review or revision of part of the care plan
Is Not warranted when
Discrete, easily reversible causes
Short term acute illness
Predictable patterns of cyclical behavior
Predicted steady improvements per current plan of care
End stage disease status*
*a full reassessment is optional depending on a clinical determination of whether the resident would benefit from the assessment. The facility is still responsible for providing necessary care and services to assist the resident to achieve his or her highest practicable well-being.
Within 14 days after the facility has determined that there has been a significant change in the resident’s physical or mental condition a significant change of condition assessment should be completed be the IDT members.
Any determination about whether a patient has experienced a significant change in status is a clinical decision.

56. Regulatory Information
See F-274 §483.20(b)(2)(ii)
For additional information of significant change of condition OR
In the RAI Manual – Significant Change of Status
Chapter 2, pp. 7-12
Chapter 3, pp. 9
The regulations and RAI manual very clearly spell out when a change of condition is considered significant and when a new assessment is required and not required. Conditions identified on the change of condition monitor and reported in standup will assist the MDS coordinator and nursing staff to identify which changes must be monitored as potential significant changes in status.

57. Daily Quality Assurance Review System
PART 2
CHANGE OF CONDITION
Daily Quality Assurance Review System

58. Change of Condition Flow Sheet

59. Completing the Change of Condition Monitor

60. Completing the COC Monitor
For this example we will be using
Change of Condition Monitors in “Forms” Packet
Change of Condition Documentation Guidelines ________
Information Packet as example charts to review
I will compile some sample that we can use for the Incident Report, 24 hour report and TO’s (See slides 36 – 38 for examples using resident #0)

61. Locating the Forms Locate the Information packet of your workbook
Next locate the Forms Packet
Remove the Forms Packet and place it side by side with the Information Packet

62. Work Session Begins
Review the resident documentation data for each resident (Information Packet)
Complete the change of condition monitor after reviewing the documentation for each sample resident (Forms Packet)

63. Completing the COC Monitor-2
Look at the Change of Condition Monitor form (Forms Packet)
Review the Legend at the top of the form
These are the codes used to complete the form
Review the Special Instructions box
These are some general monitoring guidelines

64. Review of COC Forms
Review the Legend and the columns and how to complete

65. Quality Assurance Forms
Quality Assurance Improvement COC – Daily QA Monitor
Quality Assessment Improvement – Behavior Drugs/Psychotropic Monitor

66. Quality Assessment/Improvement
Behavior Drugs/Psychotropic Monitor has been separated – Optional vs. use the Quality Assurance/Improvement – Change of Condition

67. Completing the COC Monitor-3
Fill in the Information at the top right of the form – Station One, Monitor Date, and Return by…what do you think? One day? Two?
This example will be for a new (in house acquired) pressure area identified by the night shift nurse with some follow up. See Instructors notes.

68. Daily Q A Review-5
COMMUNICATION IS KEY!

69. Daily Q A Review-6 Review agenda content – see #12 of agenda
Discuss resident or family complaints/concerns or any other problems that affect quality resident care outcomes.
Identify problems that require
Immediate follow up
Ongoing monitoring

70. Daily Q A Review-7
The Administrator or DNS assign staff to complete tasks when additional follow up is needed
Follow up tasks may include
Putting resident on high risk list
Scheduling resident review by
Weight committee
Restraint Committee
Falls Committee, etc.

71. Daily Quality Assurance Review Form (Log)
Use the Daily QA Review Form to record items assigned for follow up on agenda/COC form

72. Track small complaints, issues and concerns
To residents and families there is no such thing an “insignificant” complaint
Construct a system to
Record small complaints, issues and concerns reported by family, the resident or staff
Follow up to resolve the issue and record the outcome
Things like grandma’s afghan is not on her bed again today, the resident voicing that his room is too cold again today even though he’s wearing his sweater. Don’t just let it go. Take a note. Assess the resident for the complaint of being “cold”. Is it possible that the resident is running a temperature? Could this be the first sign of a change of condition?

73. Look for Trends
Tracking small complaints, issues and concerns allows you to look for trends
You may find pervasive issues that may otherwise go unnoticed

74. Daily Q A Review-8
Take the daily quality assurance review form out of the Forms Packet
Also, take out the sample agenda for the stand up meeting in the Forms Packet

75. Daily Q A Review-11
What benefits are there or are you having the Daily QA Review Process?
What obstacles do you FIND??
What suggestions do you have for overcoming these obstacles?

76. Make it happen!
It’s up to you!