1. CHANGE OF CONDITION Daily Quality Assurance Review System

2. Regulatory Requirements Change of condition documentation is required by Federal Regulation State Regulation

3. Change of Condition F-157 §483.10(b) The facility must immediately inform the resident; consult with the resident's physician; and, if know, notify the resident’s legal representative or an interested family member when there is…

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 significantly

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*

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 Monitor An integral part of Daily Quality Assurance Review Program – Daily Stand up “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

8. Change of Condition – Fitting into the Big Picture Daily Quality Review System

9. Daily Quality Assurance 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

10. System Benefits Reduces duplication of efforts 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”

11. 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

12. System Components 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

13. 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

14. 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

15. 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]

16. Resident/Family Concerns and Complaints -2 IDT involvement and reporting is critical – COMMUNICATE!

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Change of Condition versus Significant Change in Status Versus

27. The Clock is Ticking

28. When a COC is or is not a Significant Change in Status Is 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*

29. 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

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

31. Completing the Change of Condition Monitor

32. Completing the COC Monitor For this example we will be using Change of Condition Monitor Option II Change of Condition Documentation Guidelines Resident Documentation Packet

33. Locating the Forms Locate the “resident documentation” packet of your workbook Remove the packet and place it side by side with the Instruction Packet Next locate the Forms Packet of the resident documentation workbook Remove the forms packet and place it side by side with the resident documentation workbook

34. Work Session Begins The Instruction book will guide you through the work session (Instruction Packet) Review the resident documentation data for each resident (Resident Doc. Packet) Complete the change of condition monitor after reviewing the documentation for each sample resident (Forms Packet pp.1-2)

35. Completing the COC Monitor 2 Look at the Change of Condition Monitor form (Forms Packet pg. 1-2) Review the Legend at the bottom of the form These are the codes used to complete the form Review the Incidents and Accidents box These are some general monitoring guidelines

36. 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? Look at the Sample 24 hour report, Telephone orders and Incident Reports for Residents #0 at the front of the Resident Documentation Booklet: Review the 24 hour report for any changes of condition Did you find any? How many? What were they?

37. Compare the Data Compare the Sample Incident Report for Mrs. Anders with the 24 hour report – are there any problems noted? Is the incident report complete? Compare the 24 hour report on Mr. Smith with the telephone orders for treatment, and care plan. What do you find?

38. Compare the Data Did you find the same changes of condition listed on the 24 hour report as you found on the Telephone Orders and Incident reports? Why or why not?

39. Completing the COC Monitor 4 On the COC monitor Enter the name and room number of the resident with a COC in space #1 in the box at the top left of page 1 of the monitor form (Resident #1, Room #1) In column #1 specify what the change of condition is for resident #1

40. Competing the COC Monitor Consult the COC charting guidelines (Instruction Packet pp.8) for that condition and Using the codes in the legend check the nurses note for the condition and enter the appropriate code in the nurses note box (+ = met 0 = not met, etc) Not enough space? – Use page two of the monitor form to write narrative notes that clarify your response

41. Resident #1 Nurses Notes Nurses Notes Review the documentation in the Nurses Notes versus the guidelines Is the note complete? Is the entry objective and factual versus an opinion?

42. Examples of Objective vs. Subjective Objective (Factual) 50% of meal eaten. Drank 250 ml Shaking side rails, constant movement Striking out at nurses during care Voiding 200-300cc of clear yellow urine, no foul odor, I-100cc O-980 cc Subjective (Opinion) Appetite fair Appears restless Combative Voiding q.s.

43. Completing the COC Monitor 5 Go to the next category: Follow up note if applicable What do you think? Should there be a follow up note? Enter the appropriate code in the Follow up note box Review the next 2 categories MD Notified Resident/Family or Responsible Party notified Enter the appropriate codes

44. Completing the COC Monitor 6 Review the next four categories Ancillary Notified, if applicable Restraint Assessment Post Fall Note with investigation Informed Consent, if applicable Enter the appropriate codes

45. Completing the COC Monitor 7 Review the next two categories Order carried out on med and treatment record Order carried out - lab/x-ray Review the sample care plan entry for resident #1 Enter the appropriate codes

46. Completing the COC Monitor 8 In the next section of the monitor Enter the date shift and nurse(s) responsible for any deficiencies The bottom section of the monitor entitled “Re-monitor” will be used later at the stand up meeting.

47. Completing the COC Monitor 9 Look at the Resident #2 documentation packet Using the sample incident report review for a change of condition Complete the monitor for resident #2 using the documentation samples provided. Now review the documentation packets for residents #3, and #4 and use the telephone order samples to complete the monitor for those cases.

48. Completing the COC Monitor 10 Now that you’ve completed the monitor for all four residents, calculate the compliance of each category listed on the monitor. Compliance is calculated for each category by dividing the Number of charts where compliance was met (+) by the total number of charts reviewed, minus any that were Not Applicable x 100 3 divided by 4 x 100 = 75% compliance Enter the compliance calculation in the far right column

49. Completing the COC Monitor 11 Let’s review your results Compare the completed audit sample with your results Are the results the same? What differences are there and why? What problems did you have completing the form?

50. Commonly Asked Questions and Problems Q: What if there isn’t enough room on the form or a code to explain the deficiency? A: Enter an “x” in the box where the deficiency is and use the reverse side of the monitor, page 2, to explain in greater detail.

51. Daily Quality Assurance Review Performed at the Daily Standup Meeting Who should participate? The Administrator The DNS or assignee The Health Records Designee Representatives from all disciplines

52. Daily Q A Review -2 When should we schedule the meeting? In the morning at a consistently scheduled time– around 9:00 a.m. is common This should be a routine that everyone is aware of and plans for daily Page staff to the meeting over the intercom 5 minutes prior to starting START ON TIME!

53. Daily Q A Review -3 How should we conduct daily standup meeting? Use a prepared agenda of topics to be covered in the meeting The Administrator or Director of Nursing or another designee is usually responsible for running the meeting and preparing the agenda Go through the agenda topic by topic STAY ON TASK – Don’t get side tracked Be Brief – if more discussion is needed, schedule a set time to conclude the discussion

54. Sample Meeting Agenda Review the sample agenda form in the forms portion of the workbook (Forms pg. 5-6)

55. Daily Q A Review -4 The Health Record Designee Reviews the results of completed change of condition and new admission monitors with the team Informs and focuses everyone on resident changes The Team Reviews new admissions and the status of Medicare Part A Residents Identifies any tasks that may require follow up as a result of the changes of condition Returns completed audits from the prior meeting – saves time tracking down individuals for completed items

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

57. Daily Q A Review -6 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

58. 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.

59. Daily Quality Assurance Review Form (Log) Use the Daily QA Review Form to record items assigned for follow up (Forms pg. 7) Let’s look at the form now

60. 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 Document efforts made -don’t leave things hanging even if you can’t solve them today

61. 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

62. Daily Q A Review -8 Take the daily quality assurance review form out of the forms packet (pg. 7-8 In the forms packet) Also, take out the sample agenda for the stand up meeting (pg. 5-6 In the forms packet)

63. The Stand up Meeting Using the agenda let’s run through a stand up meeting

64. Daily Q A Review -9 Using the results of the completed change of condition monitor Identify those items that require additional follow up Review the results with the IDT Record any re-monitors assigned for a specific change of condition in the bottom box of the appropriate column of the COC monitor form

65. Daily Q A Review -10 Let’s review the process using the Change of Condition Flow Chart – pg. 9 in the Instructions packet

66. Daily Q A Review -10 What benefits are there to the Daily QA Review Process? What obstacles do you anticipate when implementing this system? What suggestions do you have for overcoming these obstacles?

67. Make it happen! It’s up to you!