CHANGE OF CONDITION Daily Quality Assurance Review System

CHANGE OF CONDITIONDaily Quality Assurance

Review System

Regulatory Requirements

Change of condition documentation is required by Federal Regulation State Regulation

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…

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


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*


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 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

Change of Condition – Fitting into the Big Picture

Daily Quality Review System

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

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”

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

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]

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 form

Complete 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


New orders for An antibiotic, Treatment, Physical or chemical restraint, New support or assistive device, Weight loss or gain, X-rays and labs


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


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


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


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

Completing the Change of Condition Monitor

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

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

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)

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


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?

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?

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?


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

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

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?

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.


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


Review the next four categories Ancillary Notified, if applicable Restraint Assessment Post Fall Note with investigation Informed Consent, if applicable



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



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.


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.


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


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?

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.

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

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!

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

Sample Meeting Agenda

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

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

Daily Q A Review-5

COMMUNICATION IS KEY!

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

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 (Forms pg. 7)

Let’s look at the form now

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

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 (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)

The Stand up Meeting

Using the agenda let’s run through a stand up meeting

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

Daily Q A Review-10

Let’s review the process using the Change of Condition Flow Chart – pg. 9 in the Instructions packet

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?

Make it happen!

It’s up to

you!

Documents

CHANGE OF CONDITION Daily Quality Assurance Review System