Short Term Health Monitoring & Change of Condition The Key to Communication

Short Term Health Monitoring & Change of Condition form SHORT-TERM HEALTH MONITOR/CHANGE OF CONDITION REPORT Date Resident Name Describe Changes of Condition; Health Concerns; Behavior Strategies Current Status (in-house, hospital, hospice, SNF, other) Interventions Initiated: Orders, TX, Meds, Diet Staff Direction/ Documentation Instructions Expected Outcome/ Anticipated Return DC Date/ Review Date Incident Report   Purpose: Residence Nurse staff instruction Stand up shift report between staff Communication report for weekly to Quality Assurance Director for All Reportable Events by Thursday.

Short Term Health Monitoring & Change of Condition Administrator, Nurse & Staff Instruction Form allows for simple communication between All parties caring for Residents and allows for us to Create a Target list of High Risk Residents Instructs Caregivers on specific acute conditions/changes of condition that need to be monitored & documented in the Residence Progress Notes Change of Condition: a change in mental or physical status that results in a need for us to provide extra or different services. A change in resident’s ability to participate in 2 or more activities of daily living, such as eating, bathing or dressing.

Short Term Health Monitoring & Change of Condition Stand-up shift report between staff Creation of a standard tool for communicating between shifts. Residence nurse, staff and Administrator to update Short Term Health Monitoring/Change of Condition form a review with staff during staff meetings. Caregivers are to communicate/update oncoming staff to status of identified residents. GOAL: Enhance Continuity of Care & Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay

Short Term Health Monitoring & Change of Condition Residence Nurse/Administrator Communication Report GOALS: To enhance the residents quality of care Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay To insure continuity of care To insure appropriate updates to Negotiated Service Plans

Short Term Health Monitoring & Change of Condition Weekly Regional Nurse Consultant Report Consolidate forms used by residence nurses and meet reporting requirements Completion of report by residence nurses to include incidents identified on Decision Tree for Event Reporting Assist RNCs with case management of complex resident issues

How to complete the Short Term Health Monitoring & Change of Condition Once a resident is identified as requiring short term monitoring, the Change of Condition form should be updated Begin with the first two columns: add the date and resident name In the 3rd column, the residence Admin &/or nurse should specify the specific condition they wish the staff to monitor & report on

How to complete the Short Term Health Monitoring & Change of Condition In the 4th column the residence nurse should indicate the current status of the resident: Did the resident remain in the house? Was the resident admitted to the hospital? Is the resident receiving services from home health, hospice out patient rehab services?

How to complete the Short Term Health Monitoring & Change of Condition The residence Admin &/or nurse should list all interventions, orders or treatments initiated due to the change of condition The residence nurse should indicate who is providing the services: home health PT, OT, Nursing, Residence Nurse, Caregivers

How to complete the Short Term Health Monitoring & Change of Condition The residence Admin & nurse should provide staff with detailed instructions for monitoring, treatments/interventions & documenting

How to complete the Short Term Health Monitoring & Change of Condition The residence Admin & nurse should indicate the residents expected outcome. Examples: skin tears/wounds-indicate the anticipated healing date, rehab services- indicate expected goal/outcome from services The Residence Admin & nurse should also indicate the anticipated return date if the resident is hospitalized or in a rehab facility

How to complete the Short Term Health Monitoring & Change of Condition The residence Admin & nurse should indicate whether they are reviewing or discontinuing the monitoring of the resident and supply date The Residence Admin & Nurse should verify that an incident report was completed by a “Yes or No” response Expected Outcome/ Anticipated Return DC Date/ Review Date Incident Report