Download Current Topics In Geriatrics

Risk Management and
Quality Improvement in LTC
Karl E. Steinberg, MD, CMD
Associate Medical Director,
Scripps Coastal Medical Center, Oceanside
President, California Association of
Long Term Care Medicine (CALTCM)
Medical Director, Las Villas de Carlsbad HC, Village
Square Nursing Center, Hospice by the Sea
Editor-in-Chief, Caring for the Ages
Objectives
 Consider When to Call Doctor
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& What to Say
Review Notification Requirements
Importance of Informed Consent & Refusal
Discuss Common Documentation
Problems/Errors
Realistic Goals for Care Plans
Explore Issues With Unrealistic
Residents & Families
Objectives
Associated Documentation Issues
& Risk Management Strategies
Vital Signs, O2 Sats
Assessments
I/Os, Hydration, Nutrition
Turning & Repositioning, Pressure Ulcers
UTI vs. Asymptomatic Bacteriuria
Issues in Diabetes, Anticoagulants, Depression
Recognize Current Negative Public Opinion
of our Industry & Strive to Improve It!
Compassion, Empathy, Human Touch Go a Long Way
Contacting the Physician
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True Emergencies: Obviously, Use Most
Immediate Method (Pager, etc.)
 May
Need to Take Action without Orders
Significant but not truly Emergent symptoms:
Consider Personal Preferences of MD/DO,
but do not compromise patient safety
 Moderate Symptoms, Need System to Ensure
Follow-Up is Obtained! (& Documented)
 Minor Symptoms (Skin Tears, Weight
Fluctuations, Non-Injury Falls)
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 Consider
Fax with Printed Confirmation Sheet
Methods of Communication
Direct/Immediate (In Person, 2-Way)
 By Telephone (Direct Conversation, 2-Way)
 By Voice Mail Message (Indirect/One-Way)
 Via Fax (Indirect/Passive, One-Way)
 Log Book or Communication Book (One-Way)
 E-mail (One-Way)
 Via EHR System
 Via Alpha Pager or Text Message (One-Way)
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Different Situations Require Different Documentation
Notification of changes.
(i) A 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—
(A) An accident involving the resident which results in injury and has the
potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial
status (i.e., a deterioration in health, mental, or psychosocial status in either
life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (i.e., a need to
discontinue an existing form of treatment due to adverse
consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident
from the facility as specified in §483.12(a).
Notification of changes.
• When in Doubt, Notify!
• Failure to Timely (“Immediately”) Notify
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Physician & Family Member May Result in
Deficiencies/Citations
Can also Result in Successful Lawsuits
Important to Document Notification
If Unsuccessful, Keep Trying
• And Keep Documenting!
Use Nursing Judgment
Call for Backup if Needed
• DON, Medical Director
• Administrator/Executive Director
Other Times to Initiate Contact
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Abnormal Vital Signs (What Does This Mean?)
Skin Breakdown
Poor Dietary or Fluid Intake
Weight Loss
Falls/Near-Falls
Abnormal Laboratory Studies
***Family Concerns ***
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Usually OK to let Family Know How to Contact Doc
Usually NOT OK to Page Doc from Nurses’ Station
for Family & Hand Phone Over! (Ambush!)
Other Times to Initiate Contact
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Resident Symptoms (Pain, Cough, Dyspnea,
Bowel Irregularities, Dysuria, Confusion, etc.)
When an Order is Not Carried Out as Directed
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Labs Not Drawn for any Reason
Medication Not Administered or Delivered (Timely)
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Can Solicit a Substitute from E-Kit if Appropriate (esp. for
Pain or when Serious Infection is Suspected)
Refusals of Medication or Treatment
Refusals of Turning & Repositioning or Use of
Splints, Adductor Pillows, Heel Protectors, etc.
Unexpected Delays in Appointments for Test/Consult
Sophie & Tessa
Established Principles for
Effective Communication
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Except in Emergencies, Take Time to Prepare!
Do An Appropriate Assessment Before Calling
Have All Information Ready for Provider
Consider Calling Responsible Party First
Assess and Mention All Relevant Diagnoses
Know the Preferred Intensity of Treatment!
It’s OK to Have an Agenda, but Be Flexible
Worth Having it Written Down Beforehand
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Consider SBAR or Similar Pre-Printed Forms
Specific Strategies for Effective
Communication/Notification
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Have All Information Ready for Physician
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Chief Complaint & Associated History
Vital Signs, Full Set, Recent!
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Actually Do a Respiratory Rate
Include Orthostatics if Appropriate
Oxygen Saturation
Results of Focused Physical Assessment
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e.g., Lung Sounds, Abdominal Exam (Bowel Sounds, Tenderness,
Distention), Cardiac Rhythm/Sounds
Check for Impaction, Check for Bladder Distention
Assess Mental Status in Comparison to Baseline
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Actually Assess Orientation—Residents Can Fool You!
Delirium Grossly Underdiagnosed & Carries Poor Prognosis
Specific Strategies for Effective
Communication/Notification
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Have Medication List Handy
Know if Resident is on Coumadin (Antibiotic Interactions)
 Know if Resident is or has been on Antibiotics recently
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Have MARs with recent Blood Glucose values if
applicable, and Current Sliding Scale Coverage
Know when last BM & Void Occurred, Meal Intake
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(Increased Risk of C. diff., Yeast, Drug Reaction, etc.)
Know Hx of Previous Impaction, Retention, Infections
Consider the Use of a Standardized Form
Can Create Facility-Specific, Symptom-Specific Forms
 Get Medical Director to Provide Input!
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Specific Strategies for Effective
Communication/Notification
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Consult with Other Personnel if Available
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CNA Usually Knows Resident Best! Talk to Them!
Therapy Staff
Social Services or Case Manager: Is Discharge Looming?
Talk to Resident and/or Family (if Non-Emergent)
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Know Code Status and Preferred Intensity of Treatment
Consider Diagnostic & Therapeutic Measures In-House
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Obtaining Labs/X-Rays
IV Hydration
IV Antibiotics
Respiratory Therapy (Nebulizers, Incentive Spirometry, Steroids, O2)
More Frequent Monitoring: Vitals, Sats, Mental Status, etc.
Define Callback Parameters
Specific Strategies for Effective
Communication/Notification
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Have Most Recent and Older Labs/XRs at Hand
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Important to Provide Baseline & Comparative Values
Have a Summary of Your Impressions & Concerns
Have an Idea of What Your Wish List for the
Situation Is—Offer it if Appropriate
Must Consider Individual Practice/Personality Styles of
Providers: In Some Instances, Tread Lightly
 Also Consider Individual Factors of Resident/Family
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Be an Advocate for Your Residents
Have a Policy Mandating Read-Back of All New
Orders, and Enforce It! (Safety First!)
Specific Strategies for Effective
Communication/Notification
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If Nurse is Uncomfortable with MD/DO/NP/PA
Response—Call an Authority within the Facility to
Discuss (DON, Admin., Medical Director, etc.)
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Need to Practice in Accordance with Your Principles
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If Something Doesn’t Feel Right, It May Not Be Right
But Also Need to Consider Your Own Limitations
In Some Cases, Turn Care Over to Another Nurse
Need to Consider Your Own Professional License
 Need to Consider Facility/Corporate P&P
 Sometimes Involves Taking Alternative Action
 If You Have Corporate Backup, Use It! (Consultant,
Regional Nursing or Risk Management Professional, etc.)
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P
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Growth Areas for Quality
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Hold Parameters on Medications
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An Excellent Idea in Principle, Should Improve Safety
Needs to Be Consistently Implemented
May Require More Frequent Monitoring
Generally Physician-Driven
Most Commonly Used with
Antihypertensives, Digoxin
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May Hold Antihypertensive for SBP<95-120
May Hold Digoxin or Beta-Blocker for AP<50-60
Also Consider What Holding Medication May Do
Should Consider Holding Opioids for
Excess Sedation or RR<8-10
 Nebulizers, Sliding Scale Insulin are Grossly
Overutilized. Rarely Truly Necessary.
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 Dehydration a Common Problem & Cause of
Change in Condition
Can Present as Lethargy, Abnormal VS (↑ HR, ↓ BP)
Vicious Cycle as Intake Diminishes Further
CNAs Often the First to Notice Subtle MS Changes, ↓ Intake
CNAs Also First Line of Defense in Prevention & Tx
Empower CNAs—Encourage Communication,
Listen To & Appreciate Their Input!
Snack/Hydration Carts A Good Idea
Sometimes, Relative “Dehydration” is Desirable (Diuretics, CHF)
 Clinical Signs of Dehydration Somewhat Unreliable
Until It is Advanced, But their Presence or Absence
Should Be Documented
Skin Turgor (Consider Forehead)
Mucous Membranes, Sunken Eyes, Dry Axilla
Lab Work More Definitive, (Not Just BUN & Creatinine: Sodium,
Urine Specific Gravity, sometimes Urine Sodium)
Dehydration Is Sometimes Unavoidable: Document
Discussion w/Responsible Party When This Occurs
Educate Family About Options
When CHF is Present, Some Degree of Iatrogenic
Dehydration Is Desirable
Dehydration Has a Bad Reputation as Cause of Death
 Largely Undeserved Reputation: Educate!!
Enlist MD/DO/NP/PA Assistance
Consider IV Hydration in Facility,
or Hypodermoclysis (Subcutaneous Infusion)
…Rather Than Automatic Shipping to ER
Nutrition: ‘Therapeutic’ Diets Not Helpful
Usually Do More Harm than Good
Families/Residents May Need Education
Growth Areas for Quality
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Dehydration Is Sometimes Unavoidable: Document
Discussion w/Responsible Party When This Occurs
Educate Family About Options
 When CHF is Present, Some Degree of Iatrogenic
Dehydration Is Desirable
 Dehydration Has a Bad Reputation as Cause of Death
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Largely Undeserved Reputation: Educate!!
Enlist MD/DO/NP/PA Assistance
Consider IV Hydration or Hypodermoclysis
(Subcutaneous Infusion)
Rather Than Automatic Shipping to ER
Nutrition: ‘Therapeutic’ Diets Not Helpful
Growth Areas for Quality
Falls: Complete post-fall analysis before
calling unless severe injury suspected or
transfer required
Check vitals including orthostatics
Full Body Check
If unwitnessed, careful consideration of possible
head injury
Fingerstick Blood Sugar if diabetic
Current Fall Prevention Measures
History of Previous Falls
Anticipate what an IDT would do
Help Doc Make Appropriate Choices (Add Tab Alarm,
Low Bed, Mats, Lap Buddy, etc.)
If your facility is “Restraint-Free,” make sure
Resident/Family aware, and that other facilities may
not have that policy (Medicolegal and Liability Issues)
Documentation Quality Issues
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Important to Individualize Charting (esp. Narrative)
Care Plans Are Often Highly Generic, Goals Unrealistic
 Narrative Notes Should Include Some Physical Assessment!
 “Call Light Within Reach”—A (Usually) Meaningless Notation
 “Alert & Verbally Responsive”:
Not Enough! Tell More!
 “URI”—Usually Not Really Upper Respiratory Tract
 Alert Charting Should Actually Be On the Alert for Something!
 Turning & Repositioning: Protocols Should Be Used and
Documented. In High Risk Residents, Maybe Every Turn!
 Education & Discussion of Risks, Benefits, Alternatives Should
Always Be Documented
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Basic Risk Management
Accept That SNFs Are Viewed Negatively by Public
 Make an Effort to Humanize Care & Caregivers
 Clarify HIPAA Issues Early On, Obtain Permission to
Discuss Resident w/All Appropriate Parties
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If You Don’t, There Will Be Bad Blood!
Don’t Be a HIPAA Zealot!
Consider Risks vs. Benefits of Discussing
Help Create Realistic Expectations
 Some Complications Unavoidable
 Train All Staff to Be Compassionate,
Empathetic & Respectful
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Foster an Attitude of Compassion
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Provide the kind of care you’d want your family to get
Always greet residents/visitors and ask if they need help
Respond promptly to phone calls and other concerns
Treat everyone in the building with respect
Have a Greeter/Receptionist (a Friendly One!)
Convene Ethics Committees when appropriate
• Use Medical Director in complex or sticky situations
• A Good Ombudsman Can Be a Great Asset
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Avoid Value Judgment in Documentation
Be complete in Documentation whenever possible
• Avoid “Charting Parties” and “Shadow Charting”
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Ensure Adequate Staffing, but Avoid Registry
• Good Evidence Exists that Consistency/Continuity of Staff with
Individual Residents Results in Improved Outcomes
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You Know Who the Problem Families Are!
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Be Proactive With These People!
Do Extra Charting, Extra Vitals, Extra Calls to Doc if needed
Document Conversations with Resident/Family
Document Conversations with Attending Physician
Involve Ombudsman When Appropriate
Try to Work Collaboratively, Do Not Bad-Mouth Anyone
Be Caring! Or Act Like It!
Have Extra Team Meetings to Address Specific Concerns
 Have
People Sign Waivers When Doing
Something that’s Against Medical Advice
• Even Though They Will Claim You Never Explained It,
Can Be Helpful in a Lawsuit
• Get Attending MD/DO and/or Medical Director to
Assist with Documentation on Problem Residents
Growth Areas for Quality
Pressure Ulcers are a Huge Source of Pain,
Medical Expenses & Liability
Also Not All Avoidable
Some Good Evidence that ‘Skin Failure’ is Part of
Dying Process, Interventions May Not Work
Always Care-Plan & Manage Pain!
Education of Resident/Family is Useful
Create Realistic Expectations
Documentation & Care Planning Critical (T&R!!)
Use Specialty Mattresses, Wound Consults Early
Saving One Lawsuit Is Worth Expense
Make Sure Physician Kept In The Loop
Participate as a Facility
CAHF: QCHF & Other Offerings
California Association of Long Term Care Medicine
(CALTCM) www.caltcm.org
 Education, Advocacy, Cutting-Edge Medical Updates,
Networking, Medical Directorship
 Annual Meeting July 10-12 in LA at Omni. Save the Date!
 POLST Implementation Pre-Conference July 10
Advancing Excellence Program
 www.nhqualitycampaign.org
 Multiple Goals/Parameters to Improve Quality
American Medical Directors Assoc. (AMDA)
 National Organization for Medical Directors
 Clinical Practice Guidelines, Toolkits
Take-Home Messages
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Transfers & Other Transitions in Care Settings
are a Major Source of Errors
…and a Great Opportunity for Growth!
Documentation is Critical: Accurate, Complete,
Individualized, Relevant, Resident-Centered
Team Approach is Optimal: Consider and
Respect All Opinions, Especially CNAs
Create (& Document) Realistic
Expectations
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When Not Possible,
Document Unrealistic Ones
Take-Home Messages
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Engage Medical Director, Ensure Interest &
Participation in Education, Organizations
Join CALTCM as a Facility: www.caltcm.org
 Medical Director Should Consider CMD Certification
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If Medical Director Not Active, Change That!
Get Outside Help When Appropriate
Devise Action Plans for Building-Specific Issues
Falls, Pressure Ulcers, Dehydration, Bacteriuria/UTI,
Identification of Delirium are Good Places to Start
 Policies & Procedures Should Be Current,
Evidence-Based, and Actually Followed!
 Consider Using AMDA’s Clinical Practice Guidelines
and Tool Kits www.amda.com
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Take-Home Messages
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Maintain Attitude of Empathy and Humanity
Consider Palliative Care Early When Appropriate
Our Work Is Valuable, Important,
Compassionate and Loving
Culture Change Is Upon Us: Let’s
Work to Improve Public Perception of Our Industry!
Keep Striving to Improve Quality
and Reward Innovation
Get Support and Input
from Medical Director