change of condition clinical care paths and notification to physicians

CHANGE OF CONDITIONClinical 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

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…

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


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


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


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

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.


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????


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.

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 responseResident 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. 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

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

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]

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 Elevated Temperature


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 ______

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

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?

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

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!

change of condition clinical care paths and notification to physicians

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