Download QIs excluded from application to patients with advanced dementia

RUNNING HEAD: QUALITY OF NURSING HOME CARE
Appendix Table 1 – Implementation of ACOVE Nursing Home Quality Indicators with Administrative Data
Condition
QI
#
Continuity of
Care
1
Continuity of
Care
2
Continuity of
Care
3
Continuity of
Care
4
ACOVE QI
IF a NH Resident is seen by a consultant
physician, THEN the consultant’s note should
document the reason for the consultation or the
referring physician’s request for consultation
should specify the reason for consultation.
IF a NH Resident was seen by a consultant,
THEN within 6 weeks, the consultant’s note
should be in the NH record or the primary care
provider’s note should document the
consultant’s recommendations or the
consultant’s changes in treatment.
IF the NH medical record documents that a
diagnostic test was ordered for a vulnerable
elder, THEN within 6 weeks, the NH record
should document one of the following: the
result of the test, or that the test was not needed
or the reason why it will not be performed, or
that the test is still pending.
IF a vulnerable elder is discharged from a
hospital to a NH, and the hospital notes or
discharge summary indicates that there is a
pending test result, THEN within 4 weeks of
hospital discharge, the NH medical record
should include the test result or indicate why
the result cannot be obtained.
Page # 1
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
F/C
I
X
F/C
I
X
F/C
F
F/C
F
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Continuity of
Care
5
Continuity of
Care
6
Continuity of
Care
7
Continuity of
Care
H1
Continuity of
Care
H2
ACOVE QI
IF a vulnerable elder is discharged from a
hospital to a NH, and the hospital medical
record specifies a follow-up appointment for a
physician visit or a treatment (e.g., physical
therapy or radiation oncology), THEN the NH
record should document that the visit or
treatment took place or that it was postponed or
not needed.
IF a vulnerable elder is transferred from a
hospital to a NH, THEN the following should
be transmitted to the NH with the patient and
recorded in the physician admission note or
orders: discharge diagnosis (es), medications on
discharge, medication allergies.
IF a NH Resident is transferred from a NH to a
hospital, THEN all of the following should be
transmitted from the NH to the hospital with the
patient and should be included in the physician
admission note or orders: diagnosis (es),
medications, and medication allergies.
IF a vulnerable elder is transferred between
emergency rooms or between acute care
facilities, THEN the medical record at the
receiving facility should include medical
records from the transferring facility, or should
acknowledge transfer of such medical records.
IF a vulnerable elder is discharged from
hospital to home or to a NH, THEN there
should be a discharge summary in the
outpatient physician or nursing home medical
record within 6 weeks.
Page # 2
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
F/C
F
X
X
F/C
I
X
F/C
I
X
F/C
I
X
F/C
I
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Dementia
1
Dementia
2
Dementia
3
Dementia
4
Dementia
5
Dementia
6
ACOVE QI
IF a vulnerable elder is admitted to the NH and
the MDS indicates any cognitive impairment
THEN the physician, other primary care
provider, or specialist should document the
result of a cognitive assessment with a validated
instrument.
IF a NH Resident has a non-English native
language, THEN baseline cognitive and
functional screening should be performed in the
patient's native language.
IF a NH Resident has dementia, THEN s/he
should be screened for depression during the
initial evaluation period.
IF a NH Resident has cognitive impairment,
THEN on admission, a health care provider
should obtain a history about resident safety
(including wandering and other problematic
behaviors), observe resident behavior and
establish a behavioral management plan that
includes how staff will deal with conflicts in the
NH.
IF a NH Resident with delirium or a potentially
reversible cognitive impairment has the
problem corrected, THEN the physician should
document that s/he has reviewed either the next
MDS cognitive score or has performed another
cognitive evaluation within 6 months.
IF a NH Resident has new or worsening
cognitive impairment, THEN the physician
should review the resident's medication list for
initiation of medications that might correspond
chronologically to the onset of dementia
symptoms.
Page # 3
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
H
S/P
E
S/P
H
X
S/P
H
X
S/P
H
Diagnosi
s
M
X
X
X
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Dementia
7
Dementia
8
Dementia
9
Dementia
10
Dementia
11
Dementia
12
Dementia
13
ACOVE QI
IF a NH Resident presents with new or
worsening cognitive impairment that
corresponds in time with the start of new
medication(s), THEN the physician should
discontinue or justify the necessity of
continuing these medications.
IF a NH Resident has signs of new or
worsening cognitive impairment and new or
worsening focal neurologic findings suggestive
of an intracranial process, THEN neuroimaging
(head CT or brain MRI) should have been
performed or considered.
IF a NH Resident is newly diagnosed with
dementia, THEN a serum B12 and a thyroid
stimulating hormone test should be performed.
IF a NH Resident with dementia has new
depression, THEN s/he should be treated for
the depression.
IF a NH Resident with mild to moderate
dementia has cerebrovascular disease, THEN
the resident should receive appropriate stroke
prophylaxis.
IF a NH Resident who is demented is at risk for
wandering, THEN the resident should wear
identification.
IF a NH Resident with dementia is to be
physically restrained in the NH, THEN the
target behavioral disturbance or safety issue
justifying use of the restraints must be
identified to the consenting person (resident or
legal guardian) and documented in the chart.
Page # 4
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
Treatmen
t
M
X
X
Diagnosi
s
T
X
Diagnosi
s
L
X
Treatmen
t
M
X
S/P
M
X
S/P
A
X
S/P
C
X
X
Deleted in
ACOVE
revision
X
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Dementia
14
Dementia
15
Dementia
H1
Depression
1
ACOVE QI
IF target behaviors for restraint use are
identified, THEN potential management
strategies other than physical restraints should
be documented by the health care team.
IF physical restraints are to be used with NH
Residents, THEN each of the following
measures should be enacted: consistent release
from the restraints at least every 2 hours,
interventions every 2 hours (or as indicated by
the patient’s conditions or needs) related to
nutrition, hydration, personal hygiene, toileting,
and range of motion exercises, and primary care
provider should order the restraints within 24
hours.
IF a vulnerable elder with dementia is to be
physically restrained in the hospital, THEN the
target behavioral disturbance or safety issue
justifying use of restraints must be identified to
the consenting person (patient or legal
guardian) and documented in the chart.
IF a NH Resident has MDS documentation of
or presents with new onset of one of the
following symptoms: sad mood, feeling down,
insomnia or difficulties with sleep, apathy or
loss of interest in pleasurable activities,
unexplained weight loss of greater than 5% in
the past month or 10% over 1 year or less,
unexplained fatigue or low energy, THEN the
physician, other primary care provider or
specialist should document that they conducted
or note the results of a clinical depression
assessment that includes a standardized rating
scale (not simple referral to MDS).
Page # 5
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
S/P
A
X
X
S/P
A
X
X
S/P
C
X
X
S/P
H
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Depression
2
Depression
3
Depression
4
Depression
5
ACOVE QI
IF a NH Resident presents with new onset or
new discovery of one of the following
conditions: cerebrovascular accident,
myocardial infarction, dementia, malignancy,
chronic pain, alcohol and substance abuse or
dependence, anxiety disorder, personality
disorder, THEN the physician, other primary
care provider or specialist should document that
they conducted or note the results of a clinical
depression assessment that includes a
standardized rating scale (not simple referral to
MDS).
IF a NH admission evaluation reveals that in
the past year the resident has a history of either
of the following: depression OR suicide
attempt, THEN the physician, other primary
care provider or specialist should document that
they conducted or note the results of a clinical
depression assessment that includes a
standardized rating scale (not simple referral to
MDS).
IF a NH Resident reports severe grief
continuing more than 2 months after the loss of
a spouse or significant relationship, THEN the
resident should be asked about depression,
treated for depression, or referred to a mental
health professional at the time of the report.
IF a NH Resident receives a diagnosis of a new
depression episode, THEN the medical record
should document at least three of the nine
Diagnostic and Statistical Manual (DSM) IV
target symptoms for major depression within
the first month of diagnosis.
Page # 6
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
H
X
S/P
H
X
S/P
H
Diagnosi
s
H
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Depression
6
Depression
7
Depression
8
Depression
9
Depression
10
ACOVE QI
IF a NH Resident receives a diagnosis of a new
depression episode, THEN the medical record
should document, on the day of diagnosis, the
presence or absence of suicidal ideation.
IF a NH Resident has thoughts of suicide,
THEN the medical record should document, on
the same date, that the patient either has no
immediate plan for suicide, or that the resident
was referred for evaluation for psychiatric
hospitalization.
IF a NH Resident receives a diagnosis of a new
depression episode, THEN the medical record
should document testing for hypothyroidism
(using a TSH level) within 1 month after or 3
months before the diagnosis.
IF a NH Resident is diagnosed with new
depression, THEN antidepressant treatment,
psychotherapy, or electroconvulsive therapy
should be started within 2 weeks after diagnosis
unless there is documentation within that period
that the resident has improved, or unless the
resident has substance abuse or dependence, in
which case treatment may wait until 8 weeks
after the resident is drug or alcohol free.
IF a NH Resident has depression with
psychotic features, THEN s/he should be
referred to a psychiatrist or receive treatment
with a combination of an antidepressant and an
anti-psychotic, or with electroconvulsive
therapy.
Page # 7
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Diagnosi
s
H
Treatmen
t
R
S/P
L
X
Treatmen
t
M
X
Treatmen
t
R
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Depression
11
Depression
12
Depression
13
Depression
14
ACOVE QI
IF a NH Resident has depression with
psychotic features (e.g., auditory hallucinations,
delusions), or has melancholic or vegetative
depression with pervasive anhedonia,
unreactive mood, psychomotor disturbances,
severe terminal insomnia, and weight and
appetite loss, THEN s/he should not be treated
with psychotherapy alone, unless s/he is unable
or unwilling to take medication.
IF a NH Resident is started on an
antidepressant medication, THEN the
following medications should not be used as
first- or second-line therapies for depression:
tertiary amine tricyclics (amitriptyline,
imipramine, doxepin, clomipramine,
trimipramine), monoamine oxiase inhibitors
(unless atypical depression is present),
benzodiazepines, AND stimulants (except
methylphenidate).
IF a NH Resident is being treated for
depression with antidepressants, THEN the
antidepressants should be prescribed at
appropriate starting doses, and they should have
an appropriate titration schedule to a therapeutic
dose, therapeutic blood level, or remission of
symptoms by 12 weeks.
IF a NH Resident with a history of cardiac
disease is started on a tricyclic antidepressant,
THEN a baseline electrocardiogram should be
performed prior to initiation of treatment, or
within three months prior to treatment.
Page # 8
Domain
Intervention
Treatmen
t
M
Treatmen
t
M
F/C
M
S/P
T
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Depression
15
Depression
16
ACOVE QI
IF a NH Resident has depression treatment
initiated, THEN all of the following should be
documented at the first 2 follow-up visits: the
degree of response to at least two of the nine
DSM-IV target symptoms for major depression,
medication side effects, if s/he is taking
antidepressant medications, and, suicidal risk, if
s/he had suicidal ideation during a previous
visit.
IF a NH Resident has no meaningful symptom
response after 6 weeks of treatment for
depression, THEN one of the following should
be initiated by the 8th week of treatment:
Optimize medication by altering dose of initial
medication OR changing to or adding a
different medication, Referral to psychiatrist (if
initial treatment was medication), OR Initiate
treatment with medication (if initial treatment
was psychotherapy alone).
Page # 9
Domain
Intervention
F/C
H
F/C
M
No IF
Admin Data
No THEN
Admin
Data
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Depression
17
Depression
18
Depression
19
Depression
20
ACOVE QI
IF a NH resident responds only partially after
12 weeks of treatment for depression, THEN at
least one of the following treatment options
should be instituted by the 16th week of
treatment: switch to a different medication class
OR add a second medication to the first (if
initial treatment includes medication) unless a
reason for keeping the resident on the same
class of antidepressant medication has been
documented, add psychotherapy (if the initial
treatment was medication), try a trial of
medication (if initial treatment was
psychotherapy without medication), consider
electroconvulsive therapy, or referral to a
psychiatrist.
IF a NH Resident has responded to
antidepressant medication, THEN s/he should
be continued on the drug at the same dosage for
at least 6 months, and at least one physician
documentation about depression should occur
during that time period.
IF a NH Resident has experienced 3 or more
episodes of depression, THEN s/he should
receive maintenance antidepressant medication
for at least 36 months.
IF a NH Resident is taking a selective serotonin
reuptake inhibitor (SSRI), THEN a monoamine
oxidase inhibitor (MAOI) should not be used
for at least two weeks after termination of
paroxetine (Paxil), sertraline (Zoloft),
fluvoxamine (Luvox), and citalopram (Celexa),
and for at least 5 weeks after termination of
fluoxetine (Prozac).
Page # 10
Domain
Intervention
No IF
Admin Data
F/C
M
X
F/C
M
F/C
M
Treatmen
t
M
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
Depression
QI
#
21
Diabetes
Mellitus
1
Diabetes
Mellitus
2
Diabetes
Mellitus
3
Diabetes
Mellitus
4
Diabetes
Mellitus
5
Diabetes
Mellitus
6
ACOVE QI
IF a NH Resident is taking a MAOI, THEN
s/he should not receive an SSRI for at least 2
weeks after termination of the MAOI.
IF a NH Resident has diabetes, THEN his or
her glycosylated hemoglobin level should be
measured at least every 12 months or care goals
or other records should indicate why this is not
appropriate.
IF a NH Resident has an elevated glycosylated
hemoglobin level, THEN s/he should be
offered a therapeutic intervention aimed at
improving glycemic control within 1 month for
Hgb A1C > 9 or care goals or other records
should indicate why this is not appropriate.
IF a NH Resident has a glucose level of > 300
mg/dl, THEN specific therapeutic intervention
aimed at glycemic control should be initiated
within 2 weeks or care goals or other records
should indicate why this is not appropriate.
IF a NH Resident with diabetes mellitus and
body weight < 120% of ideal, has adequate
glycemic control (Hgb A1C < 9.0 or glucose <
200) and is losing weight, THEN the resident
should be changed to a regular diet.
IF a NH Resident has diabetes, THEN his/her
feet should be examined by the primary care
provider at least annually.
IF a NH Resident has diabetes, THEN his or
her blood pressure should be checked monthly.
Page # 11
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Treatmen
t
M
X
Diagnosi
s
L
X
Treatmen
t
M
X
X
Treatmen
t
M
X
X
Treatmen
t
D
X
X
S/P
E
X
S/P
E
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Diabetes
Mellitus
7
Diabetes
Mellitus
8
Diabetes
Mellitus
9
Diabetes
Mellitus
10
End-of-Life
1
End-of-Life
2
ACOVE QI
IF NH Resident with diabetes has elevated
blood pressure, THEN s/he should be offered a
therapeutic intervention to lower blood pressure
within 3 months if blood pressure is > 160/>100
mmHg.
ALL NH Residents with diabetes should be
offered daily aspirin therapy.
IF NH Resident with diabetes is not blind,
THEN s/he should receive an annual dilated
eye examination performed by a specialist in
diabetes, an ophthalmologist, or an optometrist.
IF NH Resident with diabetes has proteinuria,
THEN s/he should be offered therapy with an
ACE inhibitors or ACE receptor blocker.
For ALL NH Residents WITHIN 2 weeks of
NH admission, the physician notes or orders
should document a discussion about or decision
concerning all of the following: resuscitation
status, hospital transfer status, AND advance
directives, UNLESS there is documentation that
the resident is not capable of understanding and
surrogate could not be located. This information
should remain available in the chart throughout
the resident’s stay.
IF a NH Resident with decision-making
capacity has orders to withhold or withdraw a
particular treatment modality (e.g. a DNR
order, an order not to initiate dialysis, or a do
not hospitalize order), THEN the medical
record should document (1) patient
participation in the decision, or (2) why the
patient chose not to participate in the decision.
Page # 12
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Treatmen
t
M
X
X
S/P
M
S/P
R
X
S/P
M
X
S/P
H
X
S/P
I
X
Performed
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
End-of-Life
3
End-of-Life
4
End-of-Life
5
ACOVE QI
ALL NH Residents should have in their charts
either an advance directive indicating the
resident's surrogate decision maker, OR
documentation of a discussion about who would
be a surrogate decision maker or a search for a
surrogate, OR indication that there is no
identified surrogate. Documentation should
occur within 2 weeks of admission, and this
information should remain available in the
chart.
IF a NH Resident indicates during an interview
that s/he would rather die than live permanently
comatose, permanently ventilated, or
permanently tube fed, THEN the chart should
contain documentation of a discussion of lifesustaining treatment preferences, OR the chart
should contain an advance directive, OR the
resident should indicate in interview that s/he
discussed this topic with the physician or did
not wish to discuss this.
IF a NH Resident has an advance directive in
the outpatient, inpatient, or NH medical record
or the resident reports the existence of an
advanced directive in an interview, and the
resident receives care in a second venue
(outpatient, hospital, or NH), THEN the
advance directive should be present in
subsequent inpatient and NH medical record(s),
OR the medical record should document its
existence, contents, and the reason that it is not
in the medical record.
Page # 13
Domain
Intervention
F/C
I
F/C
I
F/C
I
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
End-of-Life
6
End-of-Life
7
End-of-Life
8
End-of-Life
9
ACOVE QI
IF a NH Resident has specific treatment
preferences (e.g. DNR, no tube feeding, no
hospital transfer, etc.) documented in the
medical record, THEN these treatment
preferences should be followed.
IF a NH resident was conscious during any of
the last 7 days of life and died an expected
death, THEN there should be medical record
documentation about all of the following: pain,
the lack of pain, or elicitation of information
about pain in the last 7 days of life; spirituality,
or how the patient has been dealing with death
or religious feelings in the last 7 days of life;
AND emotional distress (presence, absence, or
inability to assess) in the last 7 days of life.
IF a noncomatose NH Resident is not expected
to survive and is withdrawn from a mechanical
ventilator or intubation with mechanical
ventilation is withheld, THEN the resident
should receive or have orders available for an
opiate or benzodiazepine or barbiturate infusion
to reduce dyspnea and the chart should
document whether the resident has dyspnea.
IF a NH resident who was having difficulty
with dyspnea in the last 7 days of life (as
ascertained via chart documentation or proxy
interview) died, THEN there should be chart
documentation of how the dyspnea was treated
or why treatment was not indicated and there
should be follow-up documentation about the
dyspnea if there is a follow-up note.
Page # 14
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
F/C
I
Diagnosi
s
H
X
X
Treatmen
t
M
X
X
Diagnosi
s
M
X
X
Deleted in
ACOVE
revision
Performed
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
End-of-Life
10
End-of-Life
H1
End-of-Life
H2
End-of-Life
H3
ACOVE QI
IF a NH resident without known family or next
of kin is admitted to the NH, THEN the chart
should document a search for next of kin.
IF a NH Resident with dementia, coma or
altered mental status is admitted to the hospital,
THEN within 48 hours of admission the
medical record should (1) contain an advance
directive indicating the patient's surrogate
decision maker, or (2) document a discussion
about who would be a surrogate decision maker
or a search for a surrogate, or (3) indicate that
there is no identified surrogate.
IF a NH Resident carries a diagnosis of severe
dementia, and is admitted to the hospital, and
survives 48 hours, THEN within 48 hours of
admission, the medical record should document
consideration of the patient's prior preferences
for care or that these could not be elicited or are
unknown.
IF a NH Resident is admitted directly to the
intensive care unit (via the emergency room)
and survives 48 hours, THEN within 48 hours
of admission, the medical record should
document consideration of the patient's
preferences for care or that these could not be
elicited or are unknown.
Page # 15
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
F/C
F
X
X
F/C
I
X
F/C
I
X
F/C
I
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
End-of-Life
QI
#
H4
Falls & Mobility
Problems
1
Falls & Mobility
Problems
2
Falls & Mobility
Problems
3
Falls & Mobility
Problems
4
ACOVE QI
IF a NH Resident requires mechanical
ventilation during a hospitalization (except
short-term post-operative mechanical
ventilation or mechanical ventilation of < 48
hours), THEN the medical record should
document within 48 hours of the initiation of
mechanical ventilation the goals of care and the
patient's preference for mechanical ventilation
or why this information is unavailable.
ALL NH Residents or their proxy should be
asked about the occurrence of falls on
admission and quarterly
ALL NH Residents should have a note
documenting a physician or PCP exam for the
presence of balance or gait disturbances on
admission.
IF a NH Resident has two or more falls in a
month, THEN, in the 30 days preceding or after
the second fall, the physician or PCP should
either perform a basic fall evaluation, OR
document that this represents an ongoing
problem that has been evaluated.
IF a NH Resident has had 2 or more falls in the
past year, or a single fall with injury requiring
treatment, THEN there should be physician
documentation that a basic fall evaluation was
performed, that resulted in specific diagnostic
and therapeutic recommendations.
Page # 16
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
F/C
I
X
S/P
H
X
S/P
E
X
Diagnosi
s
E
X
X
Diagnosi
s
H
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Falls & Mobility
Problems
5
Falls & Mobility
Problems
6
Falls & Mobility
Problems
7
Falls & Mobility
Problems
8
Falls & Mobility
Problems
9
Hearing Loss
1
ACOVE QI
IF a NH Resident reports or the MDS
documents difficulty with ambulation, balance,
or mobility, THEN there should be physician
documentation that a basic gait, mobility, and
balance evaluation was performed, which
resulted in specific diagnostic impressions and
therapeutic recommendations.
IF a NH Resident demonstrates decreased
balance, decreased proprioception or increased
postural sway, THEN evaluation should be
performed for an appropriate exercise program
or an assistive device.
IF a NH Resident capable of exercise is found
to have problems with gait, strength (e.g., 4/5 or
less on manual muscle testing, or needs arms to
rise from a chair), or endurance (e.g., dyspnea
on mild exertion), THEN an exercise program
should be offered.
IF a NH Resident is found to have postural
hypotension, THEN the physician note should
document further evaluation for possible
causative factors (e.g., diabetes, medications).
IF a NH Resident is taking a medication that
commonly causes hypotension, THEN the
primary care provider should document postural
changes in blood pressure and pulse at least
once.
IF a NH Resident has MDS documentation of
decreased hearing, THEN both of the following
should be documented in the provider note: a
pertinent history related to hearing loss, and an
ear examination.
Page # 17
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Diagnosi
s
E
Treatmen
t
X
Treatmen
t
X
X
X
Diagnosi
s
H
X
X
S/P
E
X
Diagnosi
s
E
X
Deleted in
ACOVE
revision
Performed
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Hearing Loss
2
Hearing Loss
3
Hearing Loss
4
Heart Failure
1
Heart Failure
2
Heart Failure
3
Heart Failure
4
ACOVE QI
IF a NH Resident fails a (non MDS) hearing
screening, THEN s/he should be offered a
formal audiologic evaluation within 3 months.
IF a NH Resident is a hearing aid candidate,
THEN s/he should be offered referral to an
audiologist within 3 months after audiologic
exam.
IF a NH Resident has a hearing aid, THEN NH
staff should provide ongoing maintenance.
IF a NH Resident is newly diagnosed with heart
failure, THEN s/he should be offered an
evaluation of his or her LV ejection fraction
within 1 month.
IF diuretics are given to a NH Resident, THEN
the indication for the diuretic should be stated
in the medical record.
IF a NH Resident has asymptomatic left
ventricular dysfunction with a left ventricular
ejection fraction < 40%, THEN s/he should be
offered an ACE inhibit or an angiotensin
receptor antagonist.
IF a NH Resident is diagnosed with heart
failure, THEN s/he should have a history taken
at the time of diagnosis and/or NH admission
that documents the presence or absence of the
following: current symptoms of chest pain or
angina; documented coronary artery disease,
revascularization, history of hypertension,
diabetes, or hypercholesterolemia; valvular
heart disease; thyroid disease; alcohol use;
smoking; current medications; and a description
of functional capacity, e.g. New York Heart
Association Functional Status.
Page # 18
Domain
Intervention
No IF
Admin Data
Diagnosi
s
T
X
Treatmen
t
A
X
F/C
A
X
Diagnosi
s
L
F/C
I
Treatmen
t
M
Diagnosi
s
H
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Heart Failure
5
Heart Failure
6
Heart Failure
7
Heart Failure
8
ACOVE QI
IF a NH Resident is diagnosed with heart
failure, THEN s/he should have the following
elements of the physical examination
documented at the time of diagnosis or
admission to a NH: weight, blood pressure and
heart rate, lung examination, cardiac
examination, abdominal and/or lower extremity
examination.
IF a NH Resident is newly diagnosed with heart
failure, THEN s/he should undergo the
following studies within 1 month of the
diagnosis (unless they were already performed
within the prior 3 months): chest x-ray,
electrocardiogram, complete blood count,
serum sodium, potassium, and creatinine,
thyroid stimulating hormone (TSH) in residents
with atrial fibrillation or heart failure with no
obvious etiology.
IF a NH Resident returns to the NH after
hospitalization for heart failure, THEN s/he
should have follow-up that includes weight
measurement within 7 days after hospital
discharge.
IF a NH Resident has heart failure and left
ventricular ejection fraction < 40%, THEN s/he
should be offered an ACE inhibitor or an
angiotensin receptor antagonist.
Page # 19
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Diagnosi
s
E
Diagnosi
s
L
X
F/C
E
X
Treatmen
t
M
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Heart Failure
9
Heart Failure
10
Heart Failure
11
Heart Failure
12
Heart Failure
H1
Hospitalization
1
ACOVE QI
IF a NH Resident has heart failure, has left
ventricular ejection fraction < 40%, and is New
York Heart Association Class I to III, THEN
s/he should be offered a beta blocker unless a
contraindication (e.g., uncompensated heart
failure) has been documented.
IF a NH Resident with heart failure has been
treated with digoxin, THEN a digoxin level
should be checked within 1 week if additional
medications are added that affect digoxin level
(quinidine, verapamil, amiodarone) or if signs
of toxicity develop.
IF a NH Resident has heart failure and atrial
fibrillation, THEN s/he should be offered
anticoagulation to achieve an international
normalized ratio of 2.0 to 3.0.
IF a NH Resident has heart failure and atrial
fibrillation, AND s/he has documented
contraindications to anticoagulation, THEN
s/he should be offered aspirin.
IF a vulnerable elder is hospitalized with heart
failure, THEN s/he should have the following
performed within one day of hospitalization:
serum electrolytes, creatinine, and blood urea
nitrogen.
IF a vulnerable elder is admitted to the hospital
for any acute or chronic illness or any surgical
procedure, THEN the evaluation should include
within 24 hours: (1) diagnoses, (2) pre-hospital
and current medications, and (3) cognitive
status, AND at some time during hospitalization
should include: (4) emotion (mood & affect)
and (5) hearing.
Page # 20
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Treatmen
t
M
X
Diagnosi
s
L
X
S/P
M
S/P
M
Diagnosi
s
L
X
S/P
H
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Hospitalization
2
Hospitalization
3
Hospitalization
4
Hospitalization
5
Hospitalization
6
ACOVE QI
IF a hospitalized vulnerable elder is at very
high risk for venous thrombosis, THEN the
patient should have venous thromboembolism
prophylaxis.
IF a vulnerable elder enters the hospital, THEN
discharge planning should begin within 48
hours.
IF a hospitalized vulnerable elder has peptic
stress ulcer risk factors, THEN the patient
should receive prophylaxis with either H2
blockers, sucralfate, or a proton pump inhibitor.
IF a hospitalized vulnerable elder has a definite
or suspected diagnosis of delirium, THEN
potentially precipitating factors must be
searched for in at least two of the following
areas and treated if found: Medications and
drugs (psychoactive drugs, alcohol withdrawal,
benzodiazepine withdrawal), Severe Illness
(cardiac, pulmonary, CNS), Infection,
Metabolic (fluid disorders, electrolyte disorders,
impaired cerebral oxygen supply), Sensory
(pain, visual impairment, hearing impairment),
Elimination Disorders (urinary retention, fecal
impaction).
IF a vulnerable elder is to have an inpatient or
outpatient elective surgery, THEN there should
be medical record documentation of the
patient’s ability to understand risks, benefits
and consequences of the proposed surgical
operation before the operative consent form is
presented for signature.
Page # 21
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
M
X
F/C
N
X
S/P
M
X
X
Diagnosi
s
E
X
X
Diagnosi
s
H
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Hospitalization
7
Hospitalization
8
Acute Care
Services
1
Acute Care
Services
2
Acute Care
Services
3
ACOVE QI
IF a vulnerable elder enters the hospital for
non-emergent peripheral revascularization or
aortic abdominal aneurysm repair, THEN a
cardiac stress test should be performed, if not
performed in the prior year.
IF a hospitalized vulnerable elder has a new
fever (T>38.5), THEN there should be
documentation that a physician examination
was performed within 4 hours (or performed in
the last 48 hours or an alternative explanation
documented in the chart).
IF a vulnerable elder is admitted to a NH,
THEN the primary care provider’s admission
assessment should include each of the
following: diagnoses, pre-admission and current
medications, functional status (ADL & IADL),
social activity and supports, emotion (mood &
affect), hearing, vision, mobility, nutritional
status.
IF a NH Resident is at very high risk for venous
thrombosis, THEN the resident should have
appropriate venous thromboembolism
prophylaxis.
IF a NH Resident has fever (T > 38.5), THEN
a PCP should perform a physical examination
within 12 hours if fever is accompanied by
mental status changes or within 24 hours if
fever is persistent or recurrent.
Page # 22
No IF
Admin Data
Domain
Intervention
S/P
T
Treatmen
t
E
S/P
H
Treatmen
t
M
X
Diagnosi
s
E
X
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Acute Care
Services
4
Acute Care
Services
5
Acute Care
Services
6
ACOVE QI
ALL NH Residents should be screened, for at
least 3 consecutive days, for delirium using a
validated scale at each of the following times:
admission from the hospital OR if an acute
change in mental status or responsiveness
occurs.
IF a NH Resident has a definite or suspected
diagnosis of delirium, THEN potentially
precipitating factors must be searched for in at
least two of the following areas and treated if
found: Medications and drugs (psychoactive
drugs, alcohol withdrawal, benzodiazepine
withdrawal), Severe Illness (cardiac,
pulmonary, CNS), Infection, Metabolic (fluid
disorders, electrolyte disorders, impaired
cerebral oxygen supply), Sensory (pain, visual
impairment, hearing impairment), Elimination
Disorders (urinary retention, fecal impaction).
IF a NH Resident suffering from delirium or
new agitation receives haloperidol or
risperidone, THEN a low initial dose should be
used and the medical record must document
reasons for the medication, justification for
higher doses, and subsequent description of
medication effects.
Page # 23
Domain
Intervention
S/P
E
Diagnosi
s
E
Treatmen
t
M
No IF
Admin Data
No THEN
Admin
Data
X
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Acute Care
Services
7
Acute Care
Services
8
Acute Care
Services
9
Hypertension
1
Hypertension
2
ACOVE QI
IF a NH Resident develops a change in
condition (e.g., change in mental status, new
fever or infection, new stroke) or the
development of another new risk factor for
dehydration, THEN: serum sodium and serum
urea nitrogen creatinine ratio should be
measured, AND s/he should be prompted to
drink fluids with a target of 1500ml of fluids
per day unless a contraindication exists.
IF a diagnosis of dehydration without signs of
hypotension or shock has been established in a
NH Resident, THEN replacement fluid should
be administered slowly, with no more than half
of the fluid deficit being met in the first day.
IF a NH Resident has dehydration with
moderate hypernatremia (serum sodium 146 to
159 meg1L), without hypotension or shock and
with no other reason for hospitalization, THEN
initial treatment should be given in the NH by
oral or intravenous fluids or hypodermoclysis.
IF a NH Resident’s blood pressure is elevated,
THEN at least 2 follow-up blood pressure
readings should be obtained in the next month
for systolic blood pressure > 160 or diastolic
BP > 100; AND within 3 months for systolic
blood pressure 150-160 or diastolic blood
pressure 90-100.
IF a NH Resident remains hypertensive after
non-pharmacologic intervention, THEN
pharmacologic anti-hypertensive treatment
should be initiated within 3 months for systolic
BP 150-160 and diastolic BP 90-100 or within 1
month for BP 161-190.
Page # 24
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Diagnosi
s
L
Treatmen
t
M
X
X
Treatmen
t
M
X
X
Diagnosi
s
E
X
X
Treatmen
t
M
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Hypertension
3
Hypertension
4
Hypertension
5
Hypertension
6
Hypertension
7
Hypertension
8
ACOVE QI
IF a NH Resident is treated with antihypertensive medication, THEN both supine
and standing blood pressures should be
measured with each adjustment of blood
pressure medication.
IF a NH Resident is diagnosed with
hypertension and pharmacologic intervention is
initiated, THEN follow-up blood pressure
checks should occur every 2 weeks until blood
pressure control has been achieved (<150/90
mmHg).
IF a NH Resident with hypertension is treated
with pharmacologic therapy and has achieved
blood pressure control (<150/90 mmHg),
THEN follow-up blood pressure checks should
occur at least every 3 months.
IF a NH Resident has hypertension and is being
treated with a diuretic, THEN all of the
following lab tests should be checked within 10
days after initiation of therapy or after dose
adjustment: potassium, blood urea nitrogen or
creatinine, sodium.
IF a NH Resident has hypertension and renal
parenchymal disease with a serum creatinine
>1.5 mg/dl or > 300 milligrams of protein/24
hours of collected urine, THEN treatment with
an ACE inhibitor should be offered.
IF a NH Resident has hypertension and asthma,
THEN beta blocker therapy for hypertension
should not be used.
Page # 25
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
F/C
E
X
F/C
E
X
F/C
E
F/C
L
X
Treatmen
t
M
X
Treatmen
t
M
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Hypertension
9
Hypertension
10
Hypertension
11
Hypertension
12
Ischemic Heart
Disease
1
ACOVE QI
IF a NH Resident is diagnosed with new
hypertension, THEN a physical examination
within 4 weeks of the diagnosis should include
all of the following: a fundoscopic eye exam, a
lung exam, a cardiac exam, including
evaluation of pulses, an abdominal exam,
including assessment for bruits, an extremity
exam.
IF a NH Resident is newly diagnosed with
hypertension, THEN all of the following
should be performed within 4 weeks of the
diagnosis: blood chemistry (sodium, potassium,
creatinine, and fasting glucose), an
electrocardiogram.
IF a NH Resident is newly diagnosed with
hypertension, THEN there should be
documentation regarding the presence or
absence of other cardiovascular risk factors.
IF a NH Resident develops a hypertensive
emergency with a diastolic blood pressure >120
mmHg and with manifestations of critical target
organ damage (and no DNH order exists),
THEN parenteral hypertensive therapy to
reduce mean arterial blood pressure by 25%
acutely and diastolic blood pressure to 100-110
mmHg within the next several hours should be
initiated while the patient is in a monitored
setting in the hospital.
IF a NH Resident has an AMI or unstable
angina, THEN s/he should be given aspirin
therapy within 1 hour of reporting symptoms.
Page # 26
Domain
Intervention
Diagnosi
s
E
Diagnosi
s
L
Diagnosi
s
H
Treatmen
t
M
Treatmen
t
M
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Ischemic Heart
Disease
2
Ischemic Heart
Disease
3
Ischemic Heart
Disease
4
Ischemic Heart
Disease
5
Ischemic Heart
Disease
6
Ischemic Heart
Disease
7
ACOVE QI
IF a NH Resident has an AMI or unstable
angina, THEN s/he should be offered beta
blocker therapy within 12 hours of presentation.
IF a NH Resident has had a myocardial
infarction, THEN s/he should be offered a beta
blocker.
IF a NH Resident has established coronary
artery disease and LDL cholesterol >130 mg/dl
despite a trial of step II diet therapy, THEN
s/he should be offered cholesterol-lowering
medication.
IF a NH Resident has established coronary
artery disease and is not on warfarin, THEN
s/he should be offered anti-platelet therapy.
IF a NH Resident has an AMI or unstable
angina with one or more of the following: pain
refractory to medical therapy (> 1 hour on
aggressive medical therapy), recurrent
angina/ischemia at rest or with low-level
activities, ischemia accompanied by symptoms
of heart failure, and does not have
cormorbidities sufficient to preclude
angiography or revascularization, THEN s/he
should be offered urgent catheterization or the
record should document why this is not
indicated.
IF a NH Resident has an AMI by
electrocardiogram and does not have a DNH or
DNR order, THEN s/he should be transferred
to the hospital or the record should document
why transfer is not indicated.
Page # 27
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Treatmen
t
M
S/P
M
X
Treatmen
t
M
X
S/P
M
Diagnosi
s
P
X
Treatmen
t
R
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Ischemic Heart
Disease
8
Ischemic Heart
Disease
H1
Ischemic Heart
Disease
H2
Ischemic Heart
Disease
H3
Ischemic Heart
Disease
H4
Malnutrition
1
ACOVE QI
IF a NH Resident has an AMI or unstable
angina, did not undergo angiography, and does
not have advanced cormorbidities or other
contra-indications to revascularization, THEN
s/he should be offered non-invasive stress
testing between 4 and 21 days after the
infarction.
IF a NH Resident is hospitalized with an acute
myocardial infarction (AMI), THEN s/he
should undergo assessment of left ventricular
function within 3 days after hospital discharge,
unless this was performed during
hospitalization.
IF a NH Resident is admitted to a hospital for
an AMI by electrocardiography and does not
have contraindications to reperfusion therapy,
THEN s/he should be offered treatment with
reperfusion therapy.
IF a vulnerable elder has significant left main
or significant three-vessel coronary artery
disease with left ventricular ejection fraction <
50%, THEN s/he should be offered coronary
artery bypass graft surgery.
IF a vulnerable elder has had a recent
myocardial infarction or recent coronary bypass
graft surgery and is a candidate for cardiac
rehabilitation, THEN s/he should be offered
cardiac rehabilitation
ALL NH Residents should be weighed monthly
and these weights should be documented in the
medical record.
Page # 28
Domain
Intervention
No IF
Admin Data
Diagnosi
s
T
X
Diagnosi
s
T
Treatmen
t
P
X
Treatmen
t
S
X
Treatmen
t
X
X
S/P
E
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Malnutrition
2
Malnutrition
3
Malnutrition
4
Malnutrition
5
Malnutrition
6
Malnutrition
7
ACOVE QI
IF a NH Resident is at risk for malnutrition,
THEN oral intake and calorie counts should be
documented daily for at least 3 days.
IF a NH Resident has documented malnutrition,
THEN oral intake and calorie counts should be
documented daily.
IF a NH Resident is transferred to the NH for
rehabilitation/ recovery after hospitalization for
hip fracture and has evidence of nutritional
deficiency, THEN oral or enteral nutritional
protein-energy supplementation should be
initiated on admission.
IF a NH Resident has involuntary weight loss
of > 5% body weight over 1 month or > 10%
body weight over 3 months, THEN the primary
care provider (PCP) should document the
weight loss (or a related disorder) in the
medical record as an indication that the PCP has
recognized malnutrition as a potential problem.
IF the nutritional status Resident Assessment
Protocol (RAP) has been triggered in a NH
Resident, THEN the presence or absence of
malnutrition (or related disorder) should be
documented by the primary care provider.
IF a NH Resident’s reported oral intake shows
a significant (> 25%) decrease for 3 consecutive
days, THEN within 2 days an evaluation of
reasons for the decrease in oral intake should be
initiated.
Page # 29
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
S/P
D
X
X
Diagnosi
s
D
X
X
Treatmen
t
D
Diagnosi
s
I
Diagnosi
s
I
Diagnosi
s
H
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Malnutrition
8
Malnutrition
9
Malnutrition
10
Malnutrition
11
ACOVE QI
IF a NH Resident has documented involuntary
weight loss or hypoalbuminemia (< 3.5 g/dL),
THEN s/he should receive an evaluation for
relevant comorbid conditions including:
assessment of medications that might be
associated with decreased appetite (e.g.,
digoxin, fluoxetine, anticholinergics) AND
assessment of depressive symptoms (e.g., using
the Geriatric Depression Scale).
IF a NH Resident has documented involuntary
weight loss or hypoalbuminemia (< 3.5 g/dL),
THEN s/he should receive an evaluation for
potentially reversible causes of poor nutritional
intake.
IF a NH Resident has experienced recent
weight loss or hypoalbuminemia and all other
potentially reversible causes have been
addressed, THEN the medical record should
document that assistance with feeding was
offered.
IF a NH Resident has experienced recent
weight loss or hypoalbuminemia, all other
potentially reversible causes have been
addressed and behavioral nursing intervention
alone was unsuccessful, THEN the medical
record should document referral to a dietician
or consideration of nutritional supplement.
Page # 30
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Diagnosi
s
H
X
Diagnosi
s
E
X
Treatmen
t
D
X
Treatmen
t
D
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
No IF
Admin Data
QI
#
ACOVE QI
Domain
Intervention
12
IF a NH Resident has documented weight loss,
low albumin/hypocholesterolemia and has not
improved after dietary consult, trial of
prompted feeding assistance, and oral
nutritional supplements, THEN the primary
care provider should document consideration of
gastrostomy or jejunostomy tube feeding.
Treatmen
t
S
Malnutrition
13
IF a NH Resident has a feeding tube inserted,
THEN there should be documentation that one
of the following was tried first: dietician
consult, assistance with feeding or oral
nutritional supplement.
Treatmen
t
D
Malnutrition
14
Treatmen
t
S
X
Malnutrition
H1
Treatmen
t
D
X
Malnutrition
H2
S/P
L
Malnutrition
H3
Treatmen
t
D
Condition
Malnutrition
IF a NH Resident has persistent dysphagia 14
days after a stroke, THEN a gastrostomy or
jejunostomy tube feeding should be considered.
IF a vulnerable elder who was hospitalized for
a hip fracture has evidence of nutritional
deficiency (thin body habitus or low serum
albumin or prealbumin), THEN oral or enteral
nutritional protein-energy supplementation
should be initiated post-operatively.
IF a vulnerable elder is hospitalized, THEN his
or her nutritional status should be documented
during the hospitalization by evaluation of oral
intake or serum biochemical testing (e.g.
albumin, prealbumin, or cholesterol).
IF a hospitalized NH Resident is unable to take
foods orally for more than 72 hours, THEN
alternative alimentation (e.g., enteral or
parenteral) should be considered.
Page # 31
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Medication Use
1
Medication Use
2
Medication Use
3
Medication Use
4
Medication Use
5
Medication Use
6
Medication Use
7
Medication Use
8
ACOVE QI
IF a NH Resident is prescribed a new drug,
THEN all of the following should occur: the
patient, or proxy, should be told about the
purpose of the drug and important adverse
reactions, AND the order for medication should
note the targeted symptom/condition, AND a
note or order should note important potential
adverse reactions.
IF a NH Resident is prescribed a new drug,
THEN the prescribed drug should have a
clearly defined indication documented in the
record.
ALL NH Residents should have an up-to-date
medication list.
EVERY new drug that is prescribed to a NH
resident on an ongoing basis for a chronic
medical condition should have a documentation
of response to therapy within six months.
ALL NH Residents should have an annual
periodic drug regimen review.
IF a NH Resident is prescribed warfarin,
THEN an INR should be determined: within 4
days after initiation of therapy AND at least
every six weeks.
IF a NH Resident is prescribed a thiazide or
loop diuretic, THEN s/he should have
electrolytes checked at least yearly.
IF a NH Resident is prescribed an oral
hypoglycemic drug, THEN chlorpropamide
should not be used.
Page # 32
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
S/P
C
X
Treatmen
t
M
X
F/C
I
X
Treatmen
t
F
X
F/C
I
X
F/C
L
X
F/C
L
X
Treatmen
t
M
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Condition
QI
#
ACOVE QI
Domain
Intervention
Medication Use
9
NH Residents should not be prescribed a
medication with strong anticholinergic effects if
alternatives are available.
Treatmen
t
M
X
Treatmen
t
M
X
Treatmen
t
M
X
F/C
L
X
F/C
I
X
Diagnosi
s
H
X
Diagnosi
s
H
X
Diagnosi
s
P
Medication Use
10
Medication Use
11
Medication Use
12
Medication Use
H1
Osteoarthritis
1
Osteoarthritis
2
Osteoarthritis
3
IF a NH Resident does not need control of
seizures, THEN barbiturates should not be
used.
IF a NH Resident requires analgesia, THEN
meperidine should not be used.
IF a NH Resident is newly started on an ACE
inhibitor or diuretic, THEN serum potassium
and creatinine levels should be checked within
one week of the initiation of therapy.
ALL NH Residents should have an up-to-date
medication list in the hospital medical record.
IF a NH Resident has a new joint pain that is
reported to the primary care provider, THEN
the joint and peri-articular structures should be
examined within 1 month or there should be
documentation that the problem has resolved.
IF a non-OTC drug is newly prescribed to treat
joint pain, THEN evidence that the affected
joint was examined should be documented
within 4 weeks.
IF a NH Resident has monoarticular joint pain
associated with redness, warmth and/or
swelling and the patient also has an oral
temperature >38o C, and does not have a
previously established diagnosis of pseudogout
or gout, THEN a diagnostic aspiration of the
painfully swollen red joint should be performed
that day.
Page # 33
X
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Osteoarthritis
4
Osteoarthritis
5
Osteoarthritis
6
Osteoarthritis
7
Osteoarthritis
8
ACOVE QI
IF an ambulatory NH Resident is newly
diagnosed with symptomatic osteoarthritis of
the knee and has no contraindication to exercise
and is physically and mentally able to exercise,
THEN a directed or supervised strengthening
or aerobic exercise program should be
prescribed within 1 month of diagnosis.
IF an ambulatory NH Resident has had a
diagnosis of symptomatic osteoarthritis of the
knee for > 12 months and has no
contraindication to exercise and is physically
and mentally able to exercise, THEN there
should be evidence that a directed or supervised
strengthening or aerobic exercise program was
prescribed at least once since the time of
diagnosis.
IF oral pharmacologic therapy is initiated to
treat symptomatic osteoarthritis, THEN
acetaminophen should be the first drug used.
IF oral pharmacologic therapy for symptomatic
osteoarthritis is changed from acetaminophen to
a different oral agent, THEN there should be
evidence that the NH Resident has had a trial of
maximum dose acetaminophen (suitable for
age/comorbidities).
IF a NH Resident is over age 75 or has any of
the following: history of peptic ulcer disease,
history of gastrointestinal bleeding, OR current
warfarin use; AND the resident is being treated
with a non-COX-2 inhibitor NSAID, THEN
s/he should be offered treatment with
misoprostol or a proton pump inhibitor.
Page # 34
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
X
X
Treatmen
t
X
X
Treatmen
t
M
X
X
Treatmen
t
M
X
X
S/P
M
Deleted in
ACOVE
revision
Performed
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Osteoarthritis
9
Osteoporosis
1
Osteoporosis
2
Osteoporosis
3
Osteoporosis
4
Osteoporosis
5
Osteoporosis
6
ACOVE QI
IF a NH Resident is treated with nonsteroidal
anti-inflammatory drugs (NSAIDs), THEN
there should be evidence that the risks
associated with these drugs were described to
the resident, if the resident is capable of
understanding.
On admission to the NH, ALL female residents
should be offered both: calcium and vitamin D
within 1 week, AND weight bearing exercises
within 1 month.
IF a NH Resident is bedfast, THEN
mobilization should be attempted unless there is
a contraindication.
IF a NH Resident has osteoporosis, THEN
calcium and vitamin D supplements should be
prescribed within 1 month of admission or a
new diagnosis of osteoporosis.
IF a NH Resident is taking corticosteroids for
more than 1 month, THEN the resident should
also be offered calcium and vitamin D,
bisphosphonate, or calcitonin.
IF a NH Resident has a new diagnosis of
osteoporosis, THEN during the initial
evaluation period medications should be
reviewed as possibly contributing to
osteoporosis.
IF an ambulatory NH Resident has an
osteoporotic fracture diagnosed, THEN some
form of physical therapy should be prescribed
within 1 month.
Page # 35
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
C
X
S/P
C
X
S/P
X
X
S/P
M
X
S/P
M
X
Diagnosi
s
H
X
Treatmen
t
X
Deleted in
ACOVE
revision
Performed
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Osteoporosis
7
Pain
Management
1
Pain
Management
2
Pain
Management
3
Pain
Management
4
Pain
Management
5
ACOVE QI
IF a female NH resident has osteoporosis,
THEN treatment with hormone replacement
therapy, bisphosphonates or calcitonin should
be considered within 1 month of DEXA or
discovery of fracture.
ALL NH Residents should be screened for
chronic pain with documentation in the primary
care provider’s note during the initial evaluation
period AND at least quarterly.
IF a NH Resident has pain on MDS screen or is
diagnosed with chronic pain, THEN the
resident should be evaluated for depression by a
primary care provider within 1 month.
IF a NH Resident has a positive MDS screen
for pain, THEN a quantitative pain assessment
utilizing a standard pain scale should be
performed (with its use not precluded but
modified for cognitive impairment).
IF a NH Resident has a newly reported chronic
painful condition, THEN treatment should be
offered or treatment options should be
discussed within 1 week.
IF a NH Resident has a newly reported chronic
painful condition, THEN a targeted history and
physical should be performed by the primary
care provider and documented within 1 month.
Page # 36
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
M
S/P
H
X
S/P
H
X
S/P
H
X
Treatmen
t
M
X
X
Diagnosi
s
E
X
X
Deleted in
ACOVE
revision
Performed
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pain
Management
6
Pain
Management
7
Pain
Management
8
Pneumonia
1
Pneumonia
2
Pneumonia
3
ACOVE QI
IF a NH Resident has been prescribed a
nonsteroidal anti-inflammatory drug (NSAID)
for the treatment of chronic pain, THEN the
medical record should indicate whether s/he has
a history of peptic ulcer disease, and if a
positive history is present, justification of
NSAID use in place of alternative therapy
should be documented.
IF a NH Resident with chronic pain is treated
with opioids, THEN s/he should be offered a
bowel regimen or the medical record should
document the potential for constipation and/or
explain why bowel treatment is not needed.
IF a NH Resident is treated for a chronic
painful condition, THEN s/he should be
assessed for a response within 3 months.
IF a NH Resident is diagnosed with pneumonia,
THEN antibiotics should be administered
within 8 hours of diagnosis.
IF a NH Resident with pneumonia has unstable
vital signs, despite a trial of NH based therapy,
and does not have a DNH order, THEN the
resident should be transferred to the hospital or
the record should document why transfer is not
indicated.
IF a NH Resident treated for a NH acquired
pneumonia has hypoxia, THEN the resident
should be transferred to a hospital (if a DNH
order does not exist), receive oxygen therapy in
the NH, or the record should document why
that is not indicated.
Page # 37
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
M
X
Treatmen
t
M
X
F/C
H
X
Treatmen
t
M
X
Treatmen
t
R
X
Treatmen
t
R
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pneumonia
4
Pneumonia
5
Pneumonia
6
Pneumonia
7
Pneumonia
8
ACOVE QI
IF a NH Resident is not known to have
received a pneumococcal vaccine or received
the vaccine more than 5 years ago (if prior to
age 65), THEN a pneumococcal vaccine should
be offered.
IF a NH Resident has no history of
anaphylactic hypersensitivity to eggs or to other
components of the influenza vaccine, THEN
the resident should be offered an annual
influenza vaccination.
IF pneumococcal and/or influenza vaccination
rates among residents of a NH are low, THEN
methods to increase the rate of vaccination
should be employed.
ALL NH health care workers should receive a
vaccination for influenza, if the health care
worker does not have contraindications to the
vaccine.
IF a NH Resident with NH acquired pneumonia
is to be switched from parenteral to oral
antimicrobial therapy, THEN the resident must
meet the following criteria: resident’s condition
is improving clinically (i.e., improved cough,
resolution of fever, decreased leukocytosis),
resident is clinically stable (i.e., heart rate > 100
beats/min; systolic blood pressure < 90 mmHg;
respiratory rate > 24/min; oxygen saturation <
90% on room air), AND resident is tolerating
oral medication and/or food and fluids.
Page # 38
No THEN
Admin
Data
Domain
Intervention
No IF
Admin Data
S/P
M
X
S/P
M
X
X
S/P
M
X
X
S/P
M
X
X
Treatmen
t
E
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pneumonia
H1
Pneumonia
H2
Pneumonia
H3
Pneumonia
H4
Pressure Ulcers
1
ACOVE QI
IF a NH resident is hospitalized and s/he is
eligible for vaccination (i.e., is not up-to-date
with pneumococcal or influenza vaccination),
THEN the patient should be offered
vaccination against pneumococcus and
influenza (during flu season).
IF a NH resident is admitted to the hospital
with community acquired pneumonia with
hypoxia, THEN the patient should receive
oxygen therapy.
IF a NH Resident with community acquired
pneumonia is to be discharged from the hospital
to the NH, THEN the patient should not be
unstable on the day prior to or the day of
discharge.
IF a NH Resident is admitted to the hospital
with pneumonia, THEN antibiotics should be
administered within eight hours of presentation.
IF a NH Resident is unable to reposition him or
herself, or has limited ability to do so, THEN a
risk assessment using a multi-dimensional
standardized scale (e.g., the Braden scale or
Norton scale) should be performed on
admission and every week during the first 4
weeks.
Page # 39
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
S/P
M
X
X
Treatmen
t
M
X
X
Treatmen
t
E
X
Treatmen
t
M
X
S/P
H
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pressure Ulcers
2
Pressure Ulcers
3
Pressure Ulcers
4
Pressure Ulcers
5
Pressure Ulcers
6
ACOVE QI
IF a NH Resident is identified as “at risk” for
pressure ulcer development or a pressure ulcer
risk assessment score indicates that the person
is “at risk”, THEN within 24 hours preventive
intervention must address all of the following:
repositioning by written schedule every 2 hours
or there should be documentation that
repositioning is not needed or not tolerated,
pressure reduction (or management of tissue
loads) unless there is documentation that this is
not needed or not tolerated, AND nutritional
status.
IF a NH Resident is found to have a pressure
ulcer, THEN a nutritional assessment should be
performed within 1 week by a dietician or a
primary care provider.
IF a NH Resident is found to have a pressure
ulcer, THEN the pressure ulcer should be
assessed for the following wound
characteristics: location, depth and stage, size,
AND presence of necrotic tissue.
IF a NH Resident has a stage 2 or greater
pressure ulcer, THEN a topical antiseptic
should not be used on the wound.
IF a NH Resident presents with a clean fullthickness or a partial thickness pressure ulcer,
THEN a moist wound healing environment
should be provided with topical dressings.
Page # 40
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
N
Treatmen
t
D
X
X
Diagnosi
s
E
X
X
Treatmen
t
N
X
X
Treatmen
t
N
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pressure Ulcers
7
Pressure Ulcers
8
Pressure Ulcers
9
Pressure Ulcers
10
ACOVE QI
IF a NH Resident presents with a full thickness
sacral or trochanteric pressure ulcer covered
with necrotic debris or eschar, THEN
debridement interventions using sharp,
mechanical, enzymatic or autolytic procedures
should be instituted within 3 days of diagnosis.
IF a NH Resident has a full thickness pressure
ulcer that has not improved after 2 to 4 weeks
of treatment, THEN both of the following
should be re-assessed: the appropriateness of
the treatment plan AND the presence of
cellulitis or osteomyelitis.
IF a NH Resident has a partial thickness
pressure ulcer and has no improvement after 1
to 2 weeks of treatment, THEN the
appropriateness of the treatment plan should be
re-assessed by the primary care provider or an
RN.
IF a NH Resident with a full thickness pressure
ulcer covered with necrotic debris or eschar
presents with signs and symptoms of systemic
infection such as elevated temperature, elevated
WBC, new confusion and agitation, THEN
each of the following should be done within 12
hours: sharp debridement of the ulcer, blood
culture, initiation of antibiotics therapy, resident
and wound should be evaluated by a physician
or primary care provider.
Page # 41
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
Treatmen
t
P
X
X
F/C
E
X
X
F/C
E
X
X
Treatmen
t
P
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Pressure Ulcers
H1
Pressure Ulcers
H2
Quality of
Residential Care
1
Quality of
Residential Care
2
ACOVE QI
IF a vulnerable elder is admitted to an intensive
care unit or a medical/surgical unit of a hospital
and is unable to reposition himself or herself or
has limited ability to do so, THEN risk
assessment for pressure ulcers should be
performed upon admission.
IF a vulnerable elder is identified as “at risk”
for pressure ulcer development or a pressure
ulcer risk assessment score indicates that the
person is “at risk”, THEN preventive
intervention must be instituted within 12 hours
addressing repositioning needs and pressure
reduction (or management of tissue loads).
IF a vulnerable elder is admitted to a NH,
THEN, within 2 weeks, the resident’s
preferences for daily life activities in all of the
following areas should be assessed and
documented in the record: sleep schedule,
meals, roommates, telephone access,
participation in activities, spirituality, AND
privacy.
IF a NH Resident can provide stable and
realistic preference information about daily-life
activities that are related to quality of life,
THEN the degree to which these preferences
are being met should be monitored at least
quarterly after admission.
Page # 42
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
S/P
H
X
X
S/P
N
X
S/P
H
X
F/C
F
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Quality of
Residential Care
3
Quality of
Residential Care
4
Quality of
Residential Care
5
Quality of
Residential Care
6
ACOVE QI
IF the MDS documents that a resident’s selfperformance of transfers is level 1
(supervision), level 2 (limited assistance), level
3 (extensive assistance) or level 4 (total
dependence), THEN the resident should be
offered assistance with transfer at least 3 times
a day.
IF the MDS documents that a resident’s selfperformance of dressing and/or hygiene is level
1 (supervision), level 2 (limited assistance),
level 3 (extensive assistance) or level 4 (total
dependence), THEN the resident should be
offered assistance with dressing and/or hygiene
at least twice a day.
IF the MDS documents that a resident’s selfperformance of eating is level 1 (supervision),
level 2 (limited assistance), level 3 (extensive
assistance) or level 4 (total dependence),
THEN the resident should be offered assistance
with eating at every meal.
IF the MDS documents that a resident’s selfperformance of toileting is level 1
(supervision), level 2 (limited assistance), level
3 (extensive assistance) or level 4 (total
dependence), THEN the resident should be
offered assistance with toileting: every 2 hours
while awake OR using a schedule based on
formal need assessment (24 hour voiding record
or pad test); AND whenever requested
Page # 43
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
A
X
Treatmen
t
A
X
Treatmen
t
A
X
Treatmen
t
A
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Quality of
Residential Care
7
Quality of
Residential Care
8
Quality of
Residential Care
9
ACOVE QI
IF the MDS documents that a resident’s selfperformance of any ADL (mobility, transfer,
dressing, eating, toileting, personal hygiene) is
level 1 (supervision), level 2 (limited
assistance), level 3 (extensive assistance) or
level 4 (total dependence), or the resident or
proxy reports needing assistance with an ADL,
THEN the NH staff should promote increased
independence and self-performance (e.g.,
graduated prompting protocols matched to
resident need).
IF the MDS documents that a resident’s selfperformance of any ADL (mobility, transfer,
dressing, eating, toileting, personal hygiene) is
level 1 (supervision), level 2 (limited
assistance), level 3 (extensive assistance) or
level 4 (total dependence), or the resident or
proxy reports needing assistance with an ADL,
THEN the resident should report that they
receive verbal notification or cueing before the
assistance is given, are not rushed to complete
the task and are not afraid to request assistance
when needed.
IF the MDS documents that a resident requires
assistance with any personal care activity
(dressing/personal hygiene, bathing or
continence) or the resident or proxy reports
needing assistance with any personal care
activity, THEN the resident/proxy should
report that privacy is respected (e.g., closing
curtains, closing door, not changing in public
place) when personal care assistance is
provided.
Page # 44
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
Treatmen
t
A
X
Treatmen
t
A
X
Treatmen
t
N
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Quality of
Residential Care
10
Quality of
Residential Care
11
Quality of
Residential Care
12
Quality of
Residential Care
13
Quality of
Residential Care
14
ACOVE QI
IF the NH Resident or proxy reports requesting
assistance with any ADL (mobility, transfer,
dressing, eating, toileting, personal hygiene),
THEN the resident should report that s/he is
satisfied with the timeliness of staff response to
their request.
11. ALL NH Residents with ADL limitations
should be monitored within the NH by a system
that documents the frequency, timeliness and
quality of assistance provided by staff to
residents using: direct observation by human
observer; OR resident, family or advocate
interview (after resident or proxy consent); OR
direct observation aided by monitoring systems
such as movement sensors or video cameras.
IF a NH Resident is physically inactive, THEN
the resident should be provided with assisted
exercise daily unless the resident clearly
refuses.
IF a NH Resident is capable of participating in
a structured activity program (alert, able to
understand visual or verbal cues, not restricted
to bed-rest), THEN s/he should have access to
and be prompted to participate in varied,
structured activities (beyond that of group meal
times) at least 4 days per week.
IF a NH Resident uses an assistive device such
as corrective lenses, large print reading
materials, hearing aid, hearing amplifiers,
dentures, or mobility devices, THEN the
devices should be useable and readily
accessible.
Page # 45
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
Treatmen
t
N
X
X
F/C
F
X
Treatmen
t
X
X
F/CChange
to
Treatmen
t
N
Treatmen
t
A
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Quality of
Residential Care
15
Quality of
Residential Care
16
Quality of
Residential Care
17
Quality of
Residential Care
18
ACOVE QI
IF a vulnerable elder is admitted to a NH,
THEN the chart should document or NH
resident/surrogate should report that there was a
discussion to establish goals of care. If neither
resident nor family participates in planning
goals about care, then the reason should be
clearly documented.
IF a NH Resident has a significant deterioration
in physical or mental condition that requires a
new evaluation, new medication or other
therapeutic intervention, THEN the NH
Resident or surrogate should be provided
sufficient information (e.g., prognosis,
diagnosis, options and expected outcomes) to
allow participation in diagnostic and treatment
decisions unless a surrogate cannot be
contacted.
IF a NH Resident has diabetes, hypertension or
ischemic heart disease and the condition is not
tightly controlled (e.g., glycosolated Hgb > 10,
blood pressure > 160/90), THEN goals of care
for these conditions should be clearly identified
in the record.
IF the NH staff attempt to contact the primary
care provider to discuss a significant
deterioration in resident status, and the primary
care provider does not respond to NH
notification in 1 hour, THEN the NH staff
should repeat the contact attempt within 20
minutes and if no response, call the medical
director.
Page # 46
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
I
F/C
I
X
X
F/C
I
X
X
F/C
N
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Quality of
Residential Care
19
Prevention
1
Prevention
2
Prevention
3
Prevention
4
Prevention
5
Prevention
6
ACOVE QI
IF a NH Resident is deaf or does not speak
English, THEN an interpreter and/or other
written or visual materials should be employed
to facilitate communication between the
resident and NH staff (unless NH staff speak
the language of the patient).
IF a vulnerable elder is admitted to a NH, and
the record does not describe prior evaluation of
a positive TB skin test, THEN the resident
should receive TB screening with intermediate
strength PPD (5 tuberculin units) and a repeat
PPD within 2 weeks if the first test is negative.
IF a NH Resident has a positive TB screening
or booster test, THEN a CXR should be
obtained, if one has not been performed in the
prior month.
ALL NH Residents should receive an annual
examination of the oral cavity.
IF a female NH Resident is less than age 70,
THEN she should receive screening for breast
cancer with annual clinical breast examination.
IF a NH Resident uses tobacco, THEN s/he
should receive, at least once, a complete history
of tobacco use and an assessment of nicotine
dependence.
IF a NH Resident uses tobacco regularly,
THEN on admission to the NH s/he should be
advised to quit smoking and should be offered
counseling and/or pharmacologic therapy to
stop tobacco use.
Page # 47
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
F/C
R
S/P
T
X
X
S/P
T
X
X
S/P
E
X
S/P
T
X
S/P
H
S/P
C
X
X
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Prevention
7
Prevention
8
Prevention
9
Prevention
10
Prevention
H1
Stroke
1
ACOVE QI
ALL NH Residents should receive an
assessment of their physical activity level, and
be provided with ongoing needed support (e.g.
prompting) to promote regular physical activity.
IF the MDS notes new or worsening functional
impairment or a new or worsening geriatric
syndrome, THEN the physician, other primary
care provider or specialist should document the
impairment and within 2 months a follow-up
assessment should be documented.
IF a NH Resident has teeth (or dentures),
THEN s/he should be prompted to brush teeth
(or clean dentures) daily.
An edentulous NH Resident should be assessed
for the need for dentures during the initial
evaluation period.
IF a NH Resident has valvular or congenital
heart disease, intracardiac valvular prosthesis,
hypertrophic cardiomyopathy, mitral valve
prolapse with regurgitation or previous episode
of endocarditis and a high risk procedure is
planned, THEN endocarditis antibiotic
prophylaxis should be given.
IF a NH Resident aged 65-75 has atrial
fibrillation > 48 hour duration, and has any
"high risk" condition: impaired LV function ,
hypertension or systolic BP > 160 mmHg , prior
ischemic stroke, TIA, or systemic embolism,
THEN s/he should be offered: oral
anticoagulation therapy with warfarin or
antiplatelet therapy if the medical record
documents a reason not to give anticoagulant
therapy.
Page # 48
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
S/P
X
X
S/P
E
X
S/P
N
X
S/P
E
X
S/P
M
X
S/P
M
Deleted in
ACOVE
revision
Performed
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Stroke
2
Stroke
3
Stroke
4
Stroke
5
ACOVE QI
IF a male NH Resident aged 76 or older has
atrial fibrillation of > 48 hour duration, and has
any "high risk" condition: impaired LV
function, hypertension or systolic BP > 160
mmHg, prior ischemic stroke, TIA, or systemic
embolism, THEN he should be offered:, oral
anticoagulation therapy with warfarin, or,
antiplatelet therapy if the medical record
documents a reason not to give anticoagulant
therapy.
IF a female NH Resident aged 76 years or older
has atrial fibrillation of > 48 hour duration,
THEN she should be offered: oral
anticoagulation therapy or antiplatelet therapy if
the medical record documents a reason not to
give anticoagulant therapy.
IF a NH Resident is taking warfarin for AF,
THEN an International Normalized Ratio
(INR) should be checked at all of the following
times: within 4 days of the first dose, at least
every 6 weeks, and within 1 week of starting a
medicine known to affect the anticoagulant
activity of warfarin.
IF a NH Resident under age 70 has sustained a
thrombotic stroke or TIA and if 2 lipid
measurements at least 2 weeks apart confirm
LDL > 130 and/or total cholesterol to HDL
ratio > 4, THEN the resident should be offered
treatment.
Page # 49
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
S/P
M
X
S/P
M
X
F/C
L
Treatmen
t
M
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Stroke
6
Stroke
7
Stroke
8
Stroke
9
Stroke
10
ACOVE QI
IF a NH Resident without a prior history of
stroke has a presumed stroke with hemispheric
symptoms, THEN a head CT or MRI should be
performed or the chart should note why
diagnostic imaging is not indicated.
IF a NH Resident is diagnosed with acute
atherothrombotic ischemic stroke or with a
TIA, THEN antiplatelet treatment should be
offered within 48 hours following the stroke,
unless the patient is already receiving
anticoagulant treatment.
IF a NH Resident is suspected of having a
stroke and there is no DNH order or advance
directive proscribing transfer to the hospital,
THEN the resident should be transferred to a
hospital or the chart should document why
transfer is not indicated.
IF a NH Resident has had a stroke with
resultant functional disability, and meets the
standard criteria for rehabilitation potential,
THEN the resident should be transferred to a
rehabilitation unit in a NH or hospital or offered
formal rehabilitation.
IF a male NH Resident has carotid artery
symptoms and is diagnosed with TIA or
nondisabling stroke, and the medical record
does not document that the patient is not a
candidate for carotid surgery, THEN a carotid
artery imaging study should be performed
within 4 weeks.
Page # 50
No IF
Admin Data
Domain
Intervention
Diagnosi
s
T
Treatmen
t
M
Treatmen
t
R
X
Treatmen
t
N
X
Diagnosi
s
P
X
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Stroke
H1
Stroke
H2
Stroke
H3
Urinary
Incontinence
1
ACOVE QI
IF for a NH Resident the combined risk of
surgery (patient characteristics and hospital or
surgeon experience) is 10% or greater, THEN
CEA should not be performed.
IF a NH Resident is transferred to the hospital
and started on thrombolytic therapy following a
stroke: THEN all of the following should be
true: a head CT or MRI should precede
initiation of thrombolytic therapy; sulcal
effacement, mass effect, edema, or possible
hemorrhage should not be present on
neuroimage; time from symptom onset to
initiation of thrombolytic therapy should be
documented in the medical record and should
not exceed 3 hours; absence of absolute
contraindications to thrombolysis should be
documented in the medical record; tPA should
be used; AND NINDS exclusion criteria should
not be present.
IF a NH Resident is admitted to the hospital
with a diagnosis of acute ischemic or
hemorrhagic stroke, THEN s/he should be
admitted to a specialized acute or combined
acute and rehabilitative stroke unit, or
transferred to a specialized stroke unit if such a
unit is available in the hospital.
ALL NH Residents should have documentation
of the presence or absence of urinary
incontinence (UI) at the time of admission.
Page # 51
No THEN
Admin
Data
Domain
Intervention
No IF
Admin Data
Treatmen
t
S
X
Treatmen
t
P
X
Treatmen
t
X
X
S/P
H
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Urinary
Incontinence
2
Urinary
Incontinence
3
Urinary
Incontinence
4
Urinary
Incontinence
5
Urinary
Incontinence
6
ACOVE QI
IF a NH Resident has UI on admission or the
new onset of UI that persists for over 1 month,
THEN a targeted history should be obtained
that documents each of the following: mental
status, characteristics of voiding, ability to get
to toilet, prior treatment for urinary
incontinence, and importance of the problem to
the resident.
IF a NH Resident has new UI that persists for
over 1 month or UI on initial assessment,
THEN a targeted physical should be performed
that documents: rectal exam, skin exam, and
genital system exam (including a pelvic exam
for women).
IF a NH Resident has new UI that persists for
over 1 month or UI on initial assessment,
THEN the following tests should be obtained
or there should be documentation explaining
why the test was not completed: dipstick
urinalysis, post void residual, and 24 hour
voiding record.
IF a cognitively intact NH Resident who is
capable of independent toileting has
documented stress, urge, or mixed incontinence
without evidence of hematuria or high postresidual, THEN behavioral treatment should be
offered.
IF a NH Resident remains incontinent after
transient causes are treated, THEN the resident
should be placed on a 3 to 5 day toileting
assistance trial.
Page # 52
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
Domain
Intervention
Diagnosi
s
H
Diagnosi
s
E
X
X
Diagnosi
s
T
X
X
Treatmen
t
C
X
Treatmen
t
A
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Urinary
Incontinence
7
Urinary
Incontinence
8
Urinary
Incontinence
9
Urinary
Incontinence
10
ACOVE QI
IF a NH Resident who is incapable of
independent toileting is found on a toileting
assistance trial to be capable of appropriately
using the toilet over 65% of the time, THEN
the resident should be placed on a toilet
assistance program.
IF a NH Resident has new UI or UI at the time
of new evaluation, THEN treatment options
should be discussed with the resident, if s/he is
capable of understanding, or the proxy if the
resident is not capable of understanding.
IF a NH Resident with a PVR < 200cc
continues to have 2 or more incontinence
episodes/day despite receiving assisted toileting
2 times/day, THEN the resident should be
offered either behavioral or pharmacological
therapy in combination with the assisted
toileting program.
IF a NH Resident has a chronic urinary
retention and overflow UI, is not a candidate for
a more definitive procedure, does not have
severe physical or mental impairments, and
indwelling urethral catheterization is used,
THEN there should be documentation in the
medical or NH record that s/he has (1) terminal
illness or (2) haspressure ulcers in the relevant
area or (3) that resident prefers indwelling
catheter.
Page # 53
Domain
Intervention
No IF
Admin Data
No THEN
Admin
Data
Treatmen
t
A
X
X
Treatmen
t
C
X
X
Treatmen
t
C
X
X
Diagnosi
s
I
X
X
Deleted in
ACOVE
revision
Performed
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Urinary
Incontinence
11
Urinary
Incontinence
12
Urinary
Incontinence
H1
Vision Care
1
Vision Care
2
Vision Care
3
ACOVE QI
IF a NH Resident has clinically significant
overflow UI, and indwelling urethral
catheterization is used, THEN there should be
documentation that the resident is not a
candidate for alternative interventions as a
result of severe physical or mental impairments
or does not wish alternative interventions.
IF a NH Resident undergoes surgery or
periurethral injections for UI, THEN subtracted
cystometry should be performed prior to the
procedure.
IF a female vulnerable elder has documented
Stress UI caused by isolated intrinsic sphincter
deficiency (ISD) or ISD with coexistent
hypermobility and she undergoes surgical
correction, THEN a sling or artificial sphincter
procedure should be used.
IF a NH Resident is prescribed an ocular
therapeutic regimen either in the eye clinic or in
the hospital, THEN there should be
documentation that the regimen was
administered in the NH as prescribed.
IF a NH Resident is not totally blind, THEN an
eye exam including assessment of visual acuity
should be performed every 2 years.
IF a NH Resident has sudden-onset visual
changes, eye pain, corneal opacity, or severe
purulent discharge, THEN the resident should
be examined within 72 hours by a person
skilled at ophthalmologic examination.
Page # 54
Domain
Intervention
Diagnosi
s
I
S/P
T
S/P
S
F/C
M
S/P
R
Diagnosi
s
R
No IF
Admin Data
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Vision Care
4
Vision Care
5
Vision Care
6
Vision Care
7
Vision Care
8
Vision Care
9
Vision Care
10
ACOVE QI
IF a NH Resident develops progression of a
chronic visual deficit that now interferes with
his or her ability to carry out needed or desired
activities, THEN s/he should have an
ophthalmic examination by a person skilled at
ophthalmic examination within 2 months.
IF a NH Resident is diagnosed with cataract,
THEN assessment of visual function (i.e. his or
her ability to carry out needed or desired
activities) should be performed every 12
months.
IF a NH Resident has a new diagnosis of
primary open-angle glaucoma, THEN the
initial evaluation of each eye should include the
essential components of a comprehensive eye
exam AND documentation of the optic nerve
appearance, visual field testing and
determination of an initial target pressure.
IF a NH Resident with diabetes has a retinal
exam, THEN the absence or degree of diabetic
retinopathy should be documented.
IF a NH Resident is diagnosed with a cataract
that limits the patient's ability to carry out
needed or desired activities, THEN cataract
extraction should be offered.
IF a NH Resident undergoes cataract surgery,
THEN a follow-up ocular exam should occur
within 48 hours, and a re-examination should
occur within 3 months.
IF a NH Resident with functional visual deficits
has subjective improvement on refraction,
THEN s/he should receive a primary or
updated prescription for corrective lenses.
Page # 55
Domain
Intervention
No IF
Admin Data
Diagnosi
s
R
X
Diagnosi
s
H
Diagnosi
s
E
Diagnosi
s
E
Treatmen
t
S
F/C
F
Treatmen
t
A
No THEN
Admin
Data
Deleted in
ACOVE
revision
Performed
X
X
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
Condition
QI
#
Vision Care
11
Vision Care
12
Vision Care
13
Vision Care
H1
Vision Care
H2
ACOVE QI
IF a NH Resident is not totally blind and has
primary open-angle glaucoma, THEN s/he
should have an eye exam annually that includes
measurements of visual acuity and intra-ocular
pressure, inspection of the optic nerve, slit lamp
evaluation and visual field testing or the chart
should document that the exam is not
appropriate.
IF a NH Resident with glaucoma experiences
progressive optic nerve damage on visual field
tests or optic nerve examination, THEN
treatment should be reassessed and/or advanced
at least every 3 months until the intra-ocular
pressure is lowered by at least 20% or there is
documentation that the vision loss has
stabilized.
IF a NH Resident is diagnosed with
proliferative diabetic retinopathy, THEN a
dilated eye exam should be performed at least
every 4 months.
IF a NH Resident who has been prescribed an
ocular therapeutic regimen becomes
hospitalized, THEN the regimen should be
administered in the hospital.
IF a NH Resident who uses corrective lenses
for any activities of daily living is hospitalized
(or in a nursing home) and his or her corrective
lenses are at the hospital (or nursing home),
THEN the corrective lenses should be readily
accessible to the vulnerable elder.
Domain
S/P=Screening and Prevention
Page # 56
No IF
Admin Data
No THEN
Admin
Data
Domain
Intervention
F/C
F
Treatmen
t
F
F/C
F
F/C
M
X
Treatmen
t
A
X
Deleted in
ACOVE
revision
Performed
X
X
X
X
RUNNING HEAD: QUALITY OF NURSING HOME CARE
F/C=Follow-up and Continuity
Rx=Treatment
Dx=Diagnosis
Intervention
A=Assistive device
C=Counseling
D=Dietary advice
E=Physical exam
F=Follow up
H=History
I=Information continuity
L=Lab test
M=Medication
N=Nursing
P=Complex procedure
R=Referral
S=Surgery
T=Simple test
X=Exercise, PT
Page # 57