Download Daily Quality Assurance Review System

CHANGE OF CONDITION
Clinical Care Paths and Notification to
Physicians
Regulatory Requirements

Change of condition documentation is
required by
Federal Regulation
 State Regulation
 Standards of Practice for communication with the
physician and good quality of care in the facility

Change of Condition

F-157 §483.10(b) The facility must
immediately inform the resident; consult with
the resident's physician; and, if known, notify
the resident’s legal representative or an
interested family member when there is…
Change of Condition-2

Notify when there is
An accident resulting in injury or potential injury
requiring MD intervention
 A significant change in physical, mental or
psychosocial status (i.e. deterioration in health)
 A need to alter treatment

Change of Condition-3
Title XXII 72311(a)(2)
 Nursing service shall notify the physician of

(B) Any sudden and or marked change in signs,
symptoms or behavior exhibited by the patient
 (C) Any unusual occurrence involving a patient
 (D) Change in weight of 5 lbs. (or 5%) of more in
30 days*

Change of Condition-4

Title XXII 72311(a)(2)
(E) Any untoward response to a medication or
treatment
 (F) Any error in administration of a medication or
treatment
 (G) All attempts to notify physicians shall be
noted in the patients record including the time,
method of communication and the name of the
person acknowledging contact

Change of Condition-5
The SBAR – Change of Condition process will
be used for all Changes of Condition.
 There is a Change of Condition form to be
used (H.O. #1).
 If the form does not accommodate the
change of condition, document in the Nurse
Progress Notes and use the same process to
describe the condition change, i.e.,
Situation/Presenting Problem, Vital Signs

Change of Condition-6
Evaluate/observe the condition and document
the findings and follow up with the physician;
also provide all the required notifications.
 We will review the form/format a little later.

Change of Condition
Monitor

An integral part of
Daily Stand up will review residents w/ C of C
 AKA “Continuous Quality Improvement Program”


Ensures prompt follow up and complete
documentation for any change of condition
including those identified by resident or
family complaints or concerns

Identifies trends or problems for prompt
attention and possible follow up by the CQI
Committee and Risk Management Program
SBAR

This is the reference to the
evaluation/observation if the resident and the
findings on that review.
What is the Situation or Presenting
Problem
 What are the Vital Signs and are these within
normal limits? Be prepared to discuss these
with the physician in ALL CASES when the
physician is called.

SBAR-2

Determine the area that is presenting the
primary problem for the resident; do not
dismiss other body systems,
observation/evaluate and identify those areas
that need assessment for the presenting
problem, i.e., Mental Status – this area may
be relevant to any number of conditions i.e.,,
UTI, Falls, etc.
SBAR-3
Consider if the condition is a Cardiovascular
issue
 Respiratory,
 Gastrointestinal
 Genitourinary
 Possible Infection-Generalized
 Skin Condition
 Fall
 Unplanned weight change, ….etc.

SBAR-4
While there may be other conditions, then
focus on the use of the Nurse Notes and not
the Change of Condition Form.
 If resident is placed on Oral Antibiotics then
use SNF form in addition to the Change of
Condition format as you are doing now –
aside from your Nurses Notes. Physician’s oral
antibiotic Orders for the

Change of Condition – Fitting
into the Big Picture
Quality Care
& Review
System
Acute Mental Status Care Path

When making an assessment of the Mental
Status of the resident, consider that may
affect many of the changes of conditions also
for other areas besides Mental Status.
Acute Mental Status

Lets review the Care Path and the clinical
decisions that are important for
evaluation/observation and notification to the
physician when it comes to Acute Mental
Status and/or just the Mental Status and
other conditions and how it may affect the
other changes in condition. (H.O. #2)
Change of Condition FORM

Lets review H.O. #1 the form you will
complete.
CONGESTIVE HEART FAILURE

Lets review the Care Path for Congestive
Heart Failure (H.O. #2) symptoms and the
clinical decisions that are important for
evaluation/observation and notification to the
physician.
Change of Condition FORM

Lets review H.O. #1 the form you will
complete. – Check out the Cardiovascular and
the Respiratory and the condition you are
observing/evaluating
DEHYDRATION

Lets review the Care Path for Dehydration
Failure (H.O. #3) symptoms and the clinical
decisions that are important for
evaluation/observation and notification to the
physician. Note this gives you a clue of other
areas you should evaluate/observe- i.e.
Mental Status, Functional Status, Respiratory,
GI and Skin
CHANGE OF CONDITION
FORM

Lets review H.O. #2 the form you will
complete. Check out the Dehydration, mental
status, respiratory, gastrointestinal and skin.
What are your findings on
observation/examination. Document those
findings before calling the physician.
FEVER
Review of the Care Path for Fever of
undetermined origin (H.O. #3)
 Evaluate the Mental Status, Functional Status,
Respiratory, Gastrointestinal, Skin
 Is there a change in ability to eat or drink?
 New cough, lung sound changes,
incontinence, pain, new skin condition.

CHANGE OF CONDITION
FORM

Lets review H.O.#2 Change of Condition
Form; note there is the place to document
Fever and determine if it is above the normal.
Dr. notification of the fever alone is not
enough. Evaluate the other systems to
determine if there are symptoms for any of
these areas. Also, make added notes in the
nurses notes if there is not enough space
here or you have added information.
RESPIRATORY

Review of the Respiratory Infection Care Plan
(H.O. #4) focuses on the following
Vital signs and the normal vs. abnormal.
 Consider any recent lab. X-rays
 Review results of the recent labs.-x-rays and the
positive/negative findings
 If Antibiotic. Remember to complete the Antibiotic
sheet. H.O. #_______(trisha I have to give this to
you, will fax to office)

URINARY TRACT INFECTION
Review of Urinary Tract Infection (H.O. #4)
 Consider the Vital Signs; > temp. Glucose
 Lab Testing and any urinalysis maybe already
completed and the findings,
 Look at recent blood counts, persistent
nausea and vomiting, unstable VS
 Dysuria, alone, Fever, frequency, urgency

Change of Condition Form
Review Change of Condition Form (H.O. #1)
 Consider the Vital Signs and abnormal results
 Mental Status
 GI/Hydration
 GU
 Skin
 Falls, if there was also a fall.

Vital Signs and WHY???
Review H.O. #_____ Vital Signs
 Review the Weight loss issues as well.

??????
Signs and Symptoms A, B. C??
 NURSE CONSULTANTS:::::::

DO YOU REALLY WANT TO MAKE THIS YOUR
STANDARD??? REGARDING
NOTIFICATIONS??
 Risks????

CHANGE OF CONDITION
FORM
Review Change of Condition Form
 General Instructions


On change in Resident’s condition, the licensed
nurse evaluates the situation, identifies
presenting problems, gathers information on all
applicable systems and reports key observational
findings to physician.
Change of Condition Form
Mental Status
 Cardiovascular
 Respiratory
 Gland
 Gastrointestinal/Hydration
 Genitourinary
 Possible Infection, general

CHANGE OF CONDITION
FORM-2
Skin
 Falls
 Unplanned Weight Change

CHANGE OF CONDITION
FORM-3
BACKGROUND ABD REVIEW OF VITAL SIGNS
AND FINDINGS
 Document Review of Recent labs – consider
the SBAR for the various conditions and the
abnormal findings.
 Identify any new medications recently
ordered and has the change occurred since
then???

CHANGE IN CONDITION
List any allergies as those need to be known to
tell the Physician in case there are med.
Orders
Identify the system review.
Physician’s Notification and response
Resident and Family, Resp. Rep. notified.
Add additional comments, date and sign
CHANGE OF CONDITION-2
If need additional space use the Nurses Notes,
Enter, Date, Time. Continuation of Change of
Condition for (specify)_______.
 At any time if a nurses note is not complete
before you start the C of C form, draw a
diagonal line through the page. Write See C f
C.

NO. AMERICAN..NURSE CONSULTANTS. DO
YOU WANT TO GO FURTHER WITH THE
TRAINING OR STOP HERE???
CHANGE OF CONDIITON
Review System

Used to identify
Problems
 Concerns
 Conditions

…where additional follow up, review or
referral are needed or desired
 A method of continuous quality care outcome
review
 Action/results oriented

System Benefits

Reduces duplication of efforts


Follow up tasks identified and assigned to staff
with specified due dates
Focus on
Timely identification of deficiencies/problems
 Prevention of repeat deficiencies/problems
 Continued review of follow through until
resolution so that nothing “falls through the
cracks”

System Benefits-2

Utilizes time spent in daily stand up meeting
to
Maximize results
 Obtain quality outcomes


Promotes ID team involvement in
Problem identification
 Problem solving

System Components
Change of Condition Documentation
 24 hour report/shift report
 Incident reports
 Reports of resident/family
concerns/complaints
 Change of condition monitor
 Daily quality assurance review form (log)
 Daily standup meeting

24 Hour Report





Centralizes nursing communications on a shift by
shift basis
Helps to ensure timely follow up from shift to shift
or day to day
Usually the first documented indication of a new or
impending problem or change of condition
Frequently the initial problem identifier that starts
audit trail
Important source of information for the IDT as well
as nursing
Incident Reports
Another important part of the audit trail
 Provides detailed information that must be
carefully documented, reviewed and trended
 Must be integrated into the QA process and
risk management process ongoing
 Daily review of reports to ensure quality
outcomes and timely follow up

Resident/Family Concerns
and Complaints
Frequently not picked up and processed in a
methodical manner
 An important source of information about the
resident, impending or actual problems and
changes of condition
 Need to be identified and addressed by the
IDT in a timely manner [develop your method
that works for your facility]

Resident/Family Concerns
2
and ComplaintsIDT involvement and reporting is critical –
 COMMUNICATE!

Change of Condition Monitor
Defined
Monitors information given in the 24 hour
report, incident reports and telephone orders
for completeness, accuracy and follow up
 Identifies deficiencies or “loose ends” in
change of condition documentation
 Serves as a work-plan for making corrections,
when possible and assigning additional follow
up as needed

Change of Condition Monitor
Process
Review 24 hour report, incident reports and
telephone orders that denote a change of
condition
 List all changes of condition on the monitor
form
 Complete daily prior to the standup meeting

What May Indicate a
Change of Condition?

Changes can be
Physical
 Mental or psychosocial
 Incidents/accidents


Change can be
Slow to develop and show subtle signs or
 Develop rapidly with more obvious signs and
symptoms

What May Indicate a
2
Change of Condition?
When reviewing the 24 hr. Report look for

Reports to nursing by
 Family
 C.N.A.’S
 R.N.A.’S
 Ancillary
services
…that something has occurred or is changing in
the resident’s condition
 Don’t overlook resident/family complaints

What May Indicate a
3
Change of Condition?
New orders for
 An
antibiotic,
 Treatment,
 Physical or chemical restraint,
 New support or assistive device,
 Weight loss or gain,
 X-rays and labs
What May Indicate a
4
Change of Condition?
Changes in orders can also indicate a
change of condition. For example:
Increase in dose of psychotropic medication
 A change from one type of physical restraint to
another type
 A change in type of assistive device used to treat
a condition or maintain mobility
 Change in treatment order when a site is not
responding or is worsening

What May Indicate a
5
Change of Condition?
When reviewing incident reports look for
Falls
 Medication errors
 Injuries/death resulting from defective equipment
 Resident to resident or resident to staff
altercations
 Allegations or suspected abuse
 Elopement

What May Indicate a
6
Change of Condition?
When reviewing the 24
hour report look for

Physical Changes







Cardiac distress
SOB
Chest pain
Pain or change in level of
pain
Vision loss
Weakness
Abnormal, foul smelling
drainage











Slurred speech
Loss of consciousness
Dizziness
Seizure activity
Bleeding
Lacerations or bruises
Nausea, vomiting
Abdominal distention
Change in fluid uptake
Change in mobility or
ambulation
Elevated Temperature
What May Indicate a
7
Change of Condition?
When reviewing the 24
hour report look for






Changes or onset of
Mental/Psychological
Changes
Confusion
Depression
Behavioral outbursts
(verbal or physical)
Danger to self or others
Onset of wandering






Memory loss
Suicidal thoughts or
gestures
Aggressive behavior,
striking out
Resists or refusal or care,
med or treatment
Allegations of abuse or
mistreatment
Hallucinations or delusions
Change of Condition versus
Significant Change in Status
Versus
The Clock is Ticking
When a COC Is or Is Not a
Significant Change in Status

Is




Not self limiting
Impacts more than one
area
Requires ID review or
revision of part of the
care plan
Is Not warranted when





Discrete, easily
reversible causes
Short term acute illness
Predictable patterns of
cyclical behavior
Predicted steady
improvements per
current plan of care
End stage disease
status*
Regulatory Information
See F-274 §483.20(b)(2)(ii)
 For additional information of significant
change of condition
OR
 In the RAI Manual – Significant Change of
Status

Chapter 2, pp. 7-12
 Chapter 3, pp. 9

PART 2
CHANGE OF CONDITION
Daily Quality Assurance Review System
Change of Condition Flow
Sheet

Change of Condition Flow ______
Completing the Change of
Condition Monitor
Completing the COC
Monitor

For this example we will be using
Change of Condition Monitors in “Forms” Packet
 Change of Condition Documentation Guidelines
________
 Information Packet as example charts to review

Locating the Forms
Locate the Information packet of your
workbook
 Next locate the Forms Packet
 Remove the Forms Packet and place it side by
side with the Information Packet

Work Session Begins
Review the resident documentation data for
each resident (Information Packet)
 Complete the change of condition monitor
after reviewing the documentation for each
sample resident (Forms Packet)

Completing the COC
2
MonitorLook at the Change of Condition Monitor form
(Forms Packet)
 Review the Legend at the top of the form



These are the codes used to complete the form
Review the Special Instructions box

These are some general monitoring guidelines
Review of COC Forms

Review the Legend and the columns and how
to complete
Quality Assurance Forms
Quality Assurance Improvement COC – Daily
QA Monitor
 Quality Assessment Improvement – Behavior
Drugs/Psychotropic Monitor

Quality
Assessment/Improvement

Behavior Drugs/Psychotropic Monitor has
been separated – Optional vs. use the Quality
Assurance/Improvement – Change of
Condition
Completing the COC
3
Monitor
Fill in the Information at the top right of the
form – Station One, Monitor Date, and
Return by…what do you think? One day?
Two?
Daily Q A Review-5

COMMUNICATION IS KEY!
Daily Q A Review-6
Review agenda content – see #12 of agenda
 Discuss resident or family
complaints/concerns or any other problems
that affect quality resident care outcomes.


Identify problems that require
 Immediate
follow up
 Ongoing monitoring
Daily Q A Review-7

The Administrator or DNS assign staff to
complete tasks when additional follow up is
needed

Follow up tasks may include
 Putting
resident on high risk list
 Scheduling resident review by



Weight committee
Restraint Committee
Falls Committee, etc.
Daily Quality Assurance
Review Form (Log)

Use the Daily QA Review Form to record
items assigned for follow up on agenda/COC
form
Track small complaints,
issues and concerns
To residents and families there is no such
thing an “insignificant” complaint
 Construct a system to

Record small complaints, issues and concerns
reported by family, the resident or staff
 Follow up to resolve the issue and record the
outcome

Look for Trends
Tracking small complaints, issues and
concerns allows you to look for trends
 You may find pervasive issues that may
otherwise go unnoticed

Daily Q A Review-8
Take the daily quality assurance review form
out of the Forms Packet
 Also, take out the sample agenda for the
stand up meeting in the Forms Packet

Daily Q A Review-11
What benefits are there or are you having the
Daily QA Review Process?
 What obstacles do you FIND??
 What suggestions do you have for
overcoming these obstacles?

Make it happen!
It’s up to
you!