1. CHANGE OF CONDITION Audit Process Training

2. Change Of Condition – 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

3. 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”

4. 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

5. 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

6. 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

7. 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

8. 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]

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Change of Condition versus Significant Change in Status Versus

20. The Clock is Ticking

21. 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*

22. 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

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

24. Change of Condition Flow Sheet  Change of Condition Flow Sheet _____

25. COMPLETING THE CHANGE OF CONDITION MONITOR

26.  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 COMPLETING THE COC MONITOR

27.  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 LOCATING THE FORMS

28.  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) WORK SESSION BEGINS

29.  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 COMPLETING THE COC MONITOR- 2

30.  Review the Legend and the columns and how to complete REVIEW OF COC FORMS

31.  Quality Assurance Improvement COC – Daily QA Monitor  Quality Assessment Improvement – Behavior Drugs/Psychotropic Monitor QUALITY ASSURANCE FORMS

32.  Behavior Drugs/Psychotropic Monitor has been separated – Optional vs. use the Quality Assurance/Improvement – Change of Condition QUALITY ASSESSMENT/IMPROVEMENT

33.  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? COMPLETING THE COC MONITOR- 3

34.  COMMUNICATION IS KEY! DAILY Q A REVIEW

35.  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 DAILY Q A REVIEW- 2

36.  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. DAILY Q A REVIEW- 3

37.  Use the Daily QA Review Form to record items assigned for follow up on agenda/COC form DAILY QUALITY ASSURANCE REVIEW FORM (LOG)

38.  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 TRACK SMALL COMPLAINTS, ISSUES AND CONCERNS

39.  Tracking small complaints, issues and concerns allows you to look for trends  You may find pervasive issues that may otherwise go unnoticed LOOK FOR TRENDS

40.  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 DAILY Q A REVIEW- 4

41.  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? DAILY Q A REVIEW- 5

42. Make It Happen! It’s up to you!