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

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.

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

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

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).

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

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

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.

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.

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.

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.

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

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

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

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.

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)

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

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.

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

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

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.

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.

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.

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)

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

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.

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

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

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.

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

CHANGE OF CONDITION FORM-2 Skin Falls Unplanned Weight Change

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???

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

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.

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

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.

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”

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

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

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

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

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.

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.

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

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.

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

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

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.

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.

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.

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.

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

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?

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.

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.

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.

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

Change of Condition Flow Sheet

Completing the Change of Condition Monitor

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)

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

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)

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

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

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

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

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.

Daily Q A Review-5 COMMUNICATION IS KEY!

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

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.

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

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?

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

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

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?

Make it happen! It’s up to you!