CHANGE OF CONDITION

Audit Process Training

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 reviewAction/results oriented

System Benefits

Reduces duplication of efforts Follow up tasks identified and assigned to staff with specified due

datesFocus 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 Documentation24 hour report/shift report Incident reportsReports of resident/family concerns/complaintsChange of condition monitorDaily 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 trailProvides detailed information that must be carefully

documented, reviewed and trendedMust be integrated into the QA process and risk management

process ongoingDaily 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]

Resident/Family Concerns and Complaints-2

IDT involvement and reporting is critical –COMMUNICATE!

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

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 formComplete daily prior to the standup meeting

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

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

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

What May Indicate a Change of Condition?-6

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

Versus

The Clock is Ticking

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*

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

CHANGE OF CONDITION

Daily Quality Assurance Review System

PART 2

Change of Condition Flow Sheet

Change of Condition Flow Sheet _____

COMPLETING THE CHANGE OF CONDITION 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

COMPLETING THE COC MONITOR

Locate the Information packet of your workbookNext locate the Forms PacketRemove the Forms Packet and place it side by side with the

Information Packet

LOCATING THE FORMS

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

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 formReview the Special Instructions box

These are some general monitoring guidelines

COMPLETING THE COC MONITOR-2

Review the Legend and the columns and how to complete

REVIEW OF COC FORMS

Quality Assurance Improvement COC – Daily QA MonitorQuality Assessment Improvement – Behavior

Drugs/Psychotropic Monitor

QUALITY ASSURANCE FORMS

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

QUALITY ASSESSMENT/IMPROVEMENT

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

COMMUNICATION IS KEY!

DAILY Q A REVIEW

Review agenda content – see #12 of agendaDiscuss 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

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

Use the Daily QA Review Form to record items assigned for follow up on agenda/COC form

DAILY QUALITY ASSURANCE REVIEW FORM (LOG)

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

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

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

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

Make It Happen!

It’s up to

you!