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MANAGING RISK INCIDENT REPORTS &

ABUSE INVESTIGATIONS

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Managing Risk – Incident Reports & Abuse Investigations

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POST-TEST

1. Which of the following are components of a Risk Management Program?

a. Methods to identify high risk situations

b. Thorough investigations

c. Staff know why and how to perform and investigation

d. All of the above

2. Which of the following should NOT be documented at time of a fall in Med. Record?

a. Objective statements made by resident

b. ROM check

c. Staff discipline

d. Describe injury

3. Which of the following statements is not true?

a. Data gathering for an investigation begins at the bedside

b. Only interview witnesses if abuse is suspected

c. The investigation includes an assessment of resident medical status

d. None of the above

4. Which of the following are unavoidable reasons for a pressure ulcer?

a. Braden’s was completed in error so did not identify risk

b. Failed to turn resident according to care plan

c. Resident was incontinent and did not turn self in bed


5. The following should occur?

a. Only investigate skin tears and bruises of unknown origin

b. Analysis of incidents include root cause analysis

c. Only report incidents with an injury

d. All of the above



POST TEST ANSWERS

1. Which of the following are components of a Risk Management Program? D

a. Methods to identify high risk situations

b. Thorough investigations

c. Staff know why and how to perform and investigation

d. All of the above

2. Which of the following should NOT be documented at time of a fall in Med. Record?

a. Objective statements made by resident C

b. ROM check

c. Staff discipline

d. Describe injury

3. Which of the following statements is not true? B a. Data gathering for an investigation begins at the bedside

b. Only interview witnesses if abuse is suspected

c. The investigation includes an assessment of resident medical status


4. Which of the following are unavoidable reasons for a pressure ulcer? D

a. Braden’s was completed in error so did not identify risk

b. Failed to turn resident according to care plan

c. Resident was incontinent and did not turn self in bed


B 5. The following should occur?

a. Only investigate skin tears and bruises of unknown origin

b. Analysis of incidents include root cause analysis

c. Only report incidents with an injury

d. All of the above


POLARIS GROUP

Risk Management E ent andRisk Management, Event and Abuse Investigations

POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com©

1

Risk Management Program Goals

• Prevent avoidable accidents by maintaining a culture of safetysafety

• Provide quality care

• Provide for immediate re-assessment and care plan revision

• Prevent citations


• Prevent legal actions

• Satisfied customers – residents & employees

2


Training

• Education & Orientation

M l idi i li– Multidisciplinary

– Know ‘why’

– Know how to identify and report problem areas –when to complete an incident report

– Know the steps to complete a thorough


investigation

3

QAC – Establish criteria for initiation of an incident report

Falls

• Unwitnessed, found on ground

• During Assisted Transfer

• During self transfer – bed

• During self transfer – toilet


• During self transfer – chair

• While self-ambulating

• During assisted Ambulation 4


When to complete an incident report?

MISC• Found in Hazardous Situation• Other (e.g. aspiration)• Risk/Injury related to equipmentBEHAVIORS• Resident/Resident • Resident/visitor• Resident/staff


• Resident/staff• Elopement• Unsafe wandering• Unaccompanied Exit• Self inflicted injury

5


SKIN• Acquired Stage IAcquired Stage I• Acquired Stage II• Acquired Stage III• Acquired Stage IV• Skin Tear – unknown origin• Skin Tear – known origin


g• Bruise – unknown origin• Bruise – known origin• Burn/laceration/bite/other

6



MEDICATION

R Ad i i i• Repeat Administration

• Wrong medication given

• Wrong dose/route given

• Omission

• Transcription error, no administration of med


p ,

• IV Error

7

Other reportable events

• Grievances (or complete grievance form)• Alleged complaint of abuse/neglect• Lost personal items• Infections• Restraints• Restrictive side rails


• All current pressure ulcers• Reportable/substantiated abuse/neglect complaints

8


Initial Investigation – Step One

• Step One: Often performed by charge nurse• Immediate protection of resident as indicatedImmediate protection of resident as indicated• Perform physical assessment and first aid• Begin data collection and investigation

– Examine area and equipment– Interview resident – Identify witnesses


y– Conduct witness interviews– Determine if care plan was implemented as written

• Implement change to care plan as indicated

9

Investigation – Step One

• Document incident in progress notes

• Notify family and physiciany y p y

• Determine if care plan was followed as written

• Complete incident report

• Complete Investigation form

• Complete Witness Statement form

Two options


– Two options

• Summarize interview and have staff sign

• Staff document statement themselves

• Report if suspected abuse/neglect10


Guidelines for Documentation of Event

• Develop documentation guidelines for each type of Event

• Sample: Falls…. p

– Time and describe scene

– Residents behavior prior to event if known

– Objective statements made by resident

– Head to toe (list what you actually assessed)

– ROM check


– Describe resident injury if any

– Absence or presence of pain

– First aid given

– Document VS and Ortho BP 11

Guidelines for Documentation of Event

• Document in nurses’ notes

– Document neuro signs if head injury is suspected or fallDocument neuro signs if head injury is suspected or fall was unwitnessed

– Documentation physician notification/order

– Document family notification

• Do NOT document

– Fault


– Failure to follow care plan

– Staff discipline

– Equipment failure

– “Incident Report completed” statement 12


Investigation – Step Two

• Second step – often completed by the RN Care Manager e.g. ADON, DON, MDS Nurse.– Continue investigation outlined in Step One– Clinical assessment of possible causes

• Medications• Medical• Cognitive or sensory


Cognitive or sensory• Environment• Psychosocial • Physical functioning

13

Investigation – Step Three

• Third step - Ongoing data gathering by RN Care Manager or ADON DON or department headManager, or ADON, DON or department head– Incident trending based on prior incident

information or log • Has this happened before?• Similarities/differences?• What was implemented in the past?


• Initial identification of root cause• Staff assignments• Other more complex environmental issues

14


Investigation – Step Four

• Fourth Step – IDT Team Review - Analyze and SummarizeSummarize– What is the data telling you?

• Report suspected abuse/neglect– How can this be prevented from happening again?– Utilize CAA guidelines to assist with assessment and

investigation.RN D i pr i id t r p rt d th r ll


– RN Designee processes incident report and gathers all pertinent data

• IDT team review of incident within 24 hours or next working AM.

15

Investigation – Step Four

• Summary on Investigation Form should:– Identify and list all risk factors and causal factorsy

– Any fault of staff, equipment, etc.

– If not predicable; then not avoidable

– Action plan

– Attach witness statements

• Summary note in medical Record


y– Indicate risk factors (like a CAA note)

– List changes in care plan

– If no changes, explain in summary note

• Update care plan to new interventions 16


What to for? Falls

• Fall Investigation

– What was resident doing?

• Rising?

• Sitting?

• In bed or out of bed?

• During assisted transfer?

• To chair or from chair?

I di t t f h i


– Indicate type of chair

– Brakes on w/c/bed

– Chair too low

– Foot rests appropriate

• Self ambulating? 17

What to for? Falls continued:

• What was resident doing? – Reaching– Reaching– Assisted ambulation– Sliding/leaning forward out of chair

• Location & time of fall?• Side rails?

– Up, down, per care plan?


p, , p p– Malfunctioned

• Time since last voided/toileted? • Call light within reach? Call light on?• Time since last meal? 18



• Environment/equipment a factor?

F il d i d d i d i ?– Failed or misused adaptive device?

– Device out of reach?

– Faulty equipment?

– Furniture?

– Clutter?


– Lighting/glare?

– Water on floor?

– Uneven floor or if outside uneven pavement? 19


• Mobility alarm on? Functioning? Removed by resident?

• Type of footwear?

– Non-skid shoes

– Slippers

– Socks only


Socks only

– Shoes

– Barefoot

20



• Care Plan followed as written?

– If not followed, if the resident has an injury, is there possible neglect?

• Assigned staff on break?

• Staff in orientation?

• Medical factors e.g. Parkinson’s


Medical factors e.g. Parkinson s

• Vital signs – BP lying and sitting

• Diabetic? Check blood sugar

21


• Medications

– Any new medications?

– Meds in last two hours?

– Psychoactive

– Hypertension

Sedative/hypnotic


– Sedative/hypnotic

– Narcotic

22



• Physical functioning– Gait– Upper torso weakness

• Vision/sensory – glasses/hearing aide on?– Need for contrasting colors?

• Pain?


– Sitting too long?– Seating Assessment done?– Tired?

23

What to for?Skin Tears or Bruises

• Best Practices

– Admission/Quarterly Assessments/risk tools

– General risk is standard of care prevention

– Specific risk because of history of skin tears

– Ecchymosis is not a bruise or trauma related bruise.

• Ecchymosis usually non elevated spot or blotch


• Ecchymosis usually non-elevated, spot or blotch or irregular blue or purplish patch

• Ecchymosis is usually on arms, hands, legs

24



• For a skin tear there must be a blunt or shearing gforce

• Skin tears on residents who are total care must have been inflicted by another person

• Whether from a known or unknown event, one needs to determine if skin tear (or bruise) was truly


( ) yan accident or the result of excessive force or abuse or neglect by staff.

25


• Bruise - Look for patterns of fingertip-like and or heel of hand-like bruises to upper leg and knee secondary toof hand-like bruises to upper leg and knee secondary to excessive force

• Location of bruise –– Hands and lower arms and legs may be self inflicted– Inner thigh, torso likely result of care

• Other factors


– Resident medical status/behaviors– Environment/equipment– Location when discovered– Medications

26



• If known, activity at the time the injury occurred?– Get witness statements– Get witness statements

• Start with resident; does resident know what happened?

• An alert resident would know if caused by staff

• Interview involved staff or visitor if any

– What was happening?

• Transferring, bathing, recent fall?


g, g,

• Self care/ambulating? Can resident tell us what happened?

• Staff behaviors contributed to injury?

– Was care plan followed as written?

• If not was there possible neglect or abuse? 27

What to for?Skin Tears or Bruises continued:

Known injury

• If care plan was not followed as written, is it possible neglect?

– Should have been a two person transfer, but only one person transferred and resident started to fall and received a skin tear as the one aide grabbed arm to prevent fall?


prevent fall?

– Two people transferring, same incident?

– Protecting self or another resident from injury?

– Turning sheet not used, grabbed arms to transfer28



Known injury• If care plan was not followed as written, is it possibleIf care plan was not followed as written, is it possible

neglect? – Stockings were not put on, and scraped skin on

wheelchair – Padding on rail not in and cut self on side rail – Ambulating resident with gait belt and resident fell to side,

with a skin tear from bedside table


• Possible abuse/neglect – Rough handling – Intended to injure – Consider severity of injury

29


Known injury

• Summarize findings; identify all risk factors on• Summarize findings; identify all risk factors on Investigation Form

– Any discipline or counseling of staff.

– Document witness statements

– If an “accident” then summary should indicate low i k f f i id


risk of repeat of incident

• Summary progress/IDT note in medical record

• Modify care plan as indicated to prevent repeat incident

30



• If unknown originI t i id t t i i– Interview resident to origin

• Possible self-injury?

• On or off of unit?

• Recently out of facility?

• Left facility or unit but resident doesn’t remember what happened?


pp

• Is resident ambulatory?

• Or wheelchair mobile?

– Location or injury is a factor

31


• If unknown origin

– Environmental issues or cause?

– Resident location when found?

• Bed, chair, other.

– Equipment issues?

• Side rail


• Side rail

• Mattress/side rail space

32




B h i h ld ib i j i l 72– Behaviors that could contribute to injury in last 72 hours? Seated close to a resident with behaviors?

– Risk factors?

• Medications - Coumadin, Prednisone.

• Medical status


• Fragile skin

• Ecchymosis

33



R id k h h d b k– Resident may not know what happened but knows that it was not caused by staff.

– Interview staff• Staff assigned

• Staff on duty


• Other persons that came in contact that shift

• If still no determination of when;– Interview staff going backwards in time until a

conclusion can be reached 34



• If unknown origin– Staff behaviors contributed to injury?

• Was care plan followed as written?– Identify other potential issues– Document resident statements – Document witness statements

Summarize findings; risk factors on Investigation


– Summarize findings; risk factors on Investigation Form

– Update summary in medical record– Update care plan

35


Known or unknown injury

• Reasonable conclusion of when and who

• Accidental thus not avoidable?

• Report to state per state procedures for unknown injuries or any injury


36


What to for?Acquired Pressure Ulcer

• Program Best Practices

S d di d Ri k T l d i i– Standardized Risk Tool upon admission

– Summary note of all risk factors

– Care plan to risk factors

– Weight loss/Skin Team

– One nurse performs Weekly Assessments


p y

– In compliance with current standards of practice

37


• Program Best Practices

R id /F il ifi i– Resident/Family notification

– Physician notification

– New Pressure Ulcer; Refer to IDT

– Revise care plan

– Notify physician if not improving after 2 weeks


y p y p g

– Follow care plan as written

38



• What to investigate for nosocomial PU: Ri k id ifi d i k i PU?– Risk assessment identified risk prior to PU?

– If recent CAA, were all risk factors identified? – If at risk did care plan address risk factors prior to PU?– Care plan implemented as written? Neglect? – Physician and family notified?


– Physician orders obtained?– Re-assessment of all risk factors post PU? – Care plan revised post PU?

39

What to for?Medication Error

• Note date, time, shift, who made error, discovered b h d hby whom, and when.

• Type of error – Wrong….– Medication

– Dose

– Time

R id


– Resident

– Route

– Other

40


What to for?Medication Error continued:

• Cause– Transcription error; made by whom.p ; by w– No order written– Mislabeled/outdated medication – Allergy not documented– Verified incorrectly– Other: family or resident error

• Summarize on Investigation Form


• Summarize on Investigation Form • Document witness statements • Refer to pharmacy as needed • Trend Types of medication errors• Trend Root Cause

41

What to for?Resident to Resident Altercation:

• Internal Factors?• Assessed for pain? p• Need to void/bowel movement• UTI?• Hungry

• Environmental factors• Noise – residents, TV, radio, etc.

Cl


• Clutter• Lighting• Temperature• Arrangement of furniture

42


What to for?Resident to Resident Altercation:

• Contributing Factors?

Wh i i f i id ?– What was going on at time of incident?

• Change in routine

• Staff approach

• Other resident aggravated situation?

– What cognitive factors contributed?


g

– Unfamiliar caregiver?

• Complete incident report for both residents.

• Document in both medical records.43

What to for?Unaccompanied Exit

• What is Wandering?

– Cognitively impaired – excessive ambulation –leads to safety or nuisance related problems

• What is unaccompanied exit?

– Exits building but staff immediately intervene -never “lost” or “missing”


• What is Elopement?

– Successful attempt to leave facility unnoticed

– May actually get to an access road 44



• Best Practice for elopement risk

– Assess to severity of wandering and riskAssess to severity of wandering and risk

– Address in care plan

– Work closely with family regarding risk and plan

– Use photo if available – alert all staff.

– Activities, therapy, environmental changes


– Ensure all door alarms are functioning

– Wanderguard system/bracelet

– Daily checks for placement/battery--More frequent if removes 45


• Investigation for ‘unaccompanied exit”

– Door resident exited? Alert system functioning?Door resident exited? Alert system functioning?

– Behavior prior to incident?

• Pacing or wandering

• Agitated

• Recent Exit seeking


• Asking for family

• Normal time of day to go “home”

• Putting on extra clothes

• Other 46


What to doWhen Resident is “Missing”

• Missing or Elopement …..

• Charge nurse assembles all available staff and institutes a thorough search of grounds inside and outside

• If not located within 15 minutes, notify the family and administrator


– Do not imply fault

• If not located within 30 minutes, contact local police department

47


• Pertinent details

– Physical description

– Last known wearing apparel

– Any physical defects

– Any past history of habits or places he/she may frequent


q

– Whether viewed as medical emergency due to diagnosis or medications.

48



• Keep family informed of steps taken

• Notify state as required

• Document investigation of status prior to missing

• Documents each step taken with timeline

• Document all witness statements

• Report to state as required


• Report to state as required

49

Step 5 Trending and Root Cause Analysis

Log events - Document Follow-up, System issue, and Action takenAction taken

System/root cause identification

• No system issues

• Failure of complete or accurate Assessment/ Identification of risk factors prior to event


• Failure to Care Plan for Risk Factors prior to event

• Failure to implement Care Plan as written prior to

event50




• F il r t pr id T /M d rd r d• Failure to provide Tx/Med as ordered

• Staff Ratio at time of event

• Supervision of residents by Staff

• Staff training and orientation

S ff li i h d


• Staff compliance with procedures

• Failed Preventive maintenance

• Environmental factors51


• In d q t A m nt p t nt


• Inadequate Assessment post-event

• Inadequate adjustment in Care Plan post-event

• Change in Care Plan not implemented

• Other


52


Step 5Trending and Root Cause Analysis

• Action plans for root cause(s) trends

– Staff education

– Staff counseling

– Resident education

– Family education

Change in system e g orientation program


– Change in system e.g. orientation program

– Environmental changes

– QA surveillance change

– Process improvement team53

Was incident avoidable or unavoidable?

• Avoidable - examples– Medication errors– Physician orders not followed– Care plan not followed as written– Resident preferences not followed– Failure to assess risk and plan care

Failure to follow standards


– Failure to follow standards

54


Was incident avoidable or unavoidable?

• Unavoidable - examples– An unforeseeable accident – Illness or diagnoses related – Multiple risk factors – Expected outcome of care– Right to refuse – cause of refusal has been assessed,

alternatives offered and risk/benefits explained


alternatives offered and risk/benefits explained

55

Step 6 - Trending and Reporting

• Risk team reviews trends monthly

– Monthly High Risk Event Report y g p• Roll-up report for the month

• Data comes from several sources and departments

• Ideally should be computerized

• QI/QM Reports

• Updates from PIT Team updates


• QA audits routine or focused

• Quarterly Meeting

– Monthly minutes/data

– PIT team updates 56


Potential Abuse or Neglect - Need for Extended Investigation

• Extended investigation needed when potential abuse or neglect may have occurredneglect may have occurred

– Investigation is to rule/out or identify abuse/neglect

• May be reportable to state based on state rules

• Requires more extensive documentation and interviews

• Resident should be protected as indicated


• Abuse - harm was intended

• Neglect – No harm intended but intentional carelessness, negligence, or disregard of policy

57

Potential Abuse or Neglect – Extended Investigation

• Appoint an internal investigator for all suspected abuse and neglectabuse and neglect

• Gather incident report and other documents already initiated for the event

• Gather grievance document if available• Create a file


• Create a chronological record of events – List key witnesses– List key documents

58


Potential Abuse or Neglect Investigation

Result of your investigation must establish:

• What happened?• What is the incident?

• What is the alleged incident a violation of?

• When did it happen?– Date, time, shift etc.


Date, time, shift etc.

• Where did it happen? – Location

59


• Who knows what happened?– Interview anyone who may have knowledge

– Invite people to tell their story – like a movie

– Who saw what? • Where were you standing/sitting when you saw this?

• Where was resident?


• Show me what you saw

– Who heard what? • Where were you when you heard this?

• Describe what you heard? 60



• Who knows what happened?– Who did what?

• Show me what happened?

• What was happening right before?

• Has it ever happened before?

• Anyone around you might have seen it happen?


Anyone around you might have seen it happen?

61


• Preserve evidence – Secure and safeguard– Pertinent parts of the medical record - copy

– Witness statements

– Lab reports/progress notes

– Pictures, if taken

– Physical evidence (bag if necessary)


Physical evidence (bag if necessary)

– Employment and personnel files

– Records provided by any outside entity

– Applicable policy and procedure 62



• Other related factors

Frequency of complaint– Frequency of complaint

– Severity

– Aide/nurse job performance –

– Mental state of resident – may interfere with getting facts

– Mitigating circumstances e.g. dementia

R i h f


• Review the facts

• Take corrective action as indicted

• Have file available for state investigator

• Process findings as required by your state 63

Surveyor Investigative Protocol for F323

• Key points Hazards– Identification of hazards and risks– Identification of hazards and risks

• Equipment• Buckled carpet• Failed alarms• Chemicals • Unsafe water temperatures


p• Electrical • Lighting • Physical restraints• Assistive devices 64



– Analysis and Interventions and Monitoring

N d f i i– Need for supervision

• Sample – Resident with history of falls, elopement etc.

– At risk

– For hazards


For hazards

• Observation – Response

– Defective devices65


• Interview – resident, family, staff – Aware of plan to reduce risk

• Chart Review– Assessment, care plan, care plan revision

• Systems ReviewM th d f ID f h d d


– Methods for ID of hazards and response

– Response for any patterns of accidents

66



• Citations – 221 Restraints

– 272 Assessments

– 279 Care plans

– 280 Revision of care plan

– 281 Professional standards


281 Professional standards

– 253 Sufficient staff

– 521 Quality Assurance

67


• Immediate Jeopardyd d– 3rd degree burns, large 2nd degree burn

– Ingestion of corrosive

– Entrapment between side rail or improper space between side rail and mattress with injury

– Entrapment with injury in restraint


p j y

– Elopement or unsafe wandering or risk of elopement

68



• Actual Harm d– 2nd degree burn

– Short term disability, pain

– Unsafe practice lead to an injury requiring more than first aid but less than surgical intervention. Injury did require medical evaluation.


• Fracture not requiring surgery

69


• Risk for more than minimal harm – Risk for greater injury exists

– Caused minimal harm• Abrasion, bruise, skin tear

• 1st degree burns

• Pain that does not interfere with activities


• May or may not require medical evaluation

• Treatment such as first aid

70


Risk Teams

• Functioning Risk Teams - Best Practice

– Weight loss / falls / restraints

– Pressure ulcers

– Antipsychotic drug use

– Hospital transfers


– Infections

– Change in condition

71


72


Weekly Meetings

Who should be discussed:

• All new admissions

• All transfers to hospital/ER

• All residents with wounds/Pressure ulcers

• All residents with falls


• Other injuries/events in the past week

73

Weekly Meetings

Who should be discussed:

• All residents with weight loss that week - A resident should be followed in risk for 4 weeks (unless different in your policy) after weight is stabilized)

• Ne Antipsychotic/Other psychotropic


• New Antipsychotic/Other psychotropic

• Changes in condition/new orders

74


Weekly Meetings

What needs to be brought to the meeting:All incident reports/investigations for past week– All incident reports/investigations for past week

• Hospital Transfer Investigations

– Skin/Wound tracking logs

– Weight tracking forms

– Infection tracking forms


Infection tracking forms

– Intake and Output records if appropriate

– 24 hour report/new orders/Change in Condition

– Charts/Care plans for all residents being reviewed75

Weekly Meetings

What should be discussed/Questions to ask:

• Residents’ ith skin iss es• Residents’ with skin issues-– Location, type, and current status of wound

– Is wound improved, same, or deteriorated?

– What are risk factors? Care plan current?

What kind of cushions/mattresses are being used


– What kind of cushions/mattresses are being used

– What is the residents positioning schedule

– Nutritional/hydration status

– No improvement, call MD? 76


Skin Tracking Log


77

Weekly Meetings


R id i h f ll• Residents with falls –

– Review incident report and investigation

– Determine cause of fall

– Was pharmacy review done?


– Was rehab screen done?

– Care plan updated?

– Post-Assessment in chart?78


Weekly Meetings


W i h l• Weight loss –– Current weight

– How much gained or lost?

– Risk factors to be considered

– What is ideal weight?


What is ideal weight?

– What is usual weight?

– Current diet and supplement orders- care plan

– What is intake of diet and supplements79

NAR Tracking Log


80


Weekly Meetings


N P h i• New Psychotropic –– Documentation prior to order justified use

– Diagnosis supports use

– Behavior Monitor in place

– Side Effect monitoring added


Side Effect monitoring added

– Care plan updated

– Non-drug interventions

81

Weekly Meetings


O h I idOther Incidents –– Incident report complete/documentation

– Assessment and care plan revised

Infections -

New Admissions


New Admissions– Review orders/care plan

Hospital Transfers/ER –– Investigation findings – care plan updates 82


Infections


83

INTERACT Log/QI Review


84


Weekly Meetings

Documentation –• Be sure that care plan includes all problems discussed• Be sure that care plan includes all problems discussed

and that all risk factors are identified. All interventionsin place should be identified on the care plan. You canwrite a quick comment on the care plan weekly such as“reviewed at weekly risk meeting. Wound is healingand Duoderm treatment continued” or “Has lost


another 1 pound this week. Likes chocolate ensure anddrinks 100% when given. Ensure has been increasedfrom BID to TID.” Remember to date all care plancomments, changes, additions, or deletions.

85

Change In Condition

• 24 hour report

• Change of shift

• New orders

• Labs

• Other issues


86


QA Check List


87

QA Check List


88


QA Check List


89

Tasks

• Daily – Check all new admission

– Review all incident reports

– Check 24 hour report / see high risk residents

• Certain days of weekCheck skin charting


– Check skin charting

– Weekly weights

– Behavior monitors

– Pain flow sheets 90


Tasks

• Certain days of week– Check skin charting

– Weekly weights

– Behavior monitors

– Pain flow sheets

– INR


INR

• Weekly Risk Meeting

91


92


EVENT REPORT (Quality Assurance/Confidential)

Completed By Charge Nurse On Duty. Nurse/Staff: Resident: Date:_____________ Time: _________a.m. /p.m. Day of Week

Resident Statement or describe Event Scene:

Describe environment, position of resident, equipment, floor surface, and site of injury:

Describe Injury and Resident Status overall (size, depth, color, pain, bleeding, limitation in ROM-results of head-to-toe assessment, VS & Neuro checks:

Location of occurrence: Resident room Bathroom Hallway # Shower Room Nursing Station

Dining Room Activity Room Therapy Room Lobby Grounds/Parking lot

Front Exit Other Exit________________ Off Premises Unknown Other (specify) _______________

Incident: FALL Unwitnessed-found on ground During Assisted Transfer During self transfer – bed During self transfer – toilet During self transfer – chair While self-ambulating During Assisted Ambulation MISC Found in Hazardous Situation Other Risk/injury R/T equipment

SKIN Acquired Stage I Acquired Stage II Acquired Stage III Acquired Stage IV Skin Tear – unknown origin Skin Tear – known origin Bruise – unknown origin Bruise – known origin Burn/laceration/bite/other BEHAVIORS Resident/Resident

Elopement Resident/Visitor Resident/Staff Unaccompanied Exit Self inflicted injury MEDICATION Repeat Administration Wrong medication/wrong resident given Wrong dose/route given Omission IV Error Transcription error only, not administered.

Immediate Intervention initiated to protect resident: (check all that apply): Care plan updated to new interventions First Aid Physician orders/Tx ER visit/Hospital admission Med error-Req. Medical care Med error – no intervention Press. Reduction: Bed / chair Environmental Adjustment ____ _______________________________

Provide immediate protection__ ________________________________ Initiate Rise Alarm w/c / bed Initiate frequent checks_______ Lower bed Mat/mattress by bed Provide food/diversion Placed in supervised area

Oriented to call light Protective clothing-skin Toileted Put to bed Wanderguard initiated Add Enabler bar/trapeze ______________________ ______________________

Review meds PRN Med_______________ Removed S/R or restraint Added non-slip device: w/c chair Geri Initiated body pillow _______________________ _______________________

Notification of Physician: Physician notified Name:___________________ Date:_________ Time:________Notification of Responsible Party: Responsible Party notified Name:_________________________________________ No Contact. Date: Attempt Made No Contact Date/ Time: Non Staff Witnesses to event Yes/No Name:__________________________ Phone:__________ Address:__________________ Staff Witness Yes/No Name Licensed Nurse assigned:____________________

NA Assigned: First person on scene:

Page 1 of 1


INVESTIGATION (Quality Assurance/Confidential)

Resident: ____________________________ Date:____________ Time:________ Event:___________________________Initial Investigative Data: COMPLETED BY CHARGE NURSE Or UNIT MANAGER Medication factors-all events Fall or Behaviors as appropriate

New medication in last 14 days Side rails used at time of event Type of footwear: Taking psychoactive drugs? One side: ½, ¾, full, split non-skid

Name: Two side: ½ , ¾, full, split Slippers Meds that could cause bruising/bleed Was resident climbing over SR? Socks

Name: Physical Restraint in use? Shoes Taking narc/analgesic Type: Amount time since last voided

Name: Applied correctly Amount time since repositioned

Meds Cause constipation: Floor wet Call light NOT ON Meds given for bowel Regime Urine/Feces on floor Call light NOT within reach Medication contributed to event Position of bed /recent room chg Tripped

Elopement/unaccompanied exit: Factors that contributed to Event: Time since last meal: Exit Front Door Other door_______ Walker not within reach Factors that contributed to Event:

Time last seen: Clutter in room Shuffling/altered gait Unaccompanied Exit: Yes____ No____ Glare/Floor/cement Refuses to use adaptive device Actual Elopement: Yes____ No____ Vision loss/sensory impairment Refuses to ask for help Location Found:_________________________ Cognitive decline Hypotension Behaviors Other Medical: Time: _____ Noise/staff approach Need to void Mobility Alarm MEDICATION ERROR CAUSE Yes / No type: Transcription issue Alarm attached No order written Other data for all events: Alarm turned on Mislabeled/outdated medication

Assigned staff on break Alarm Functioning Allergy not documented Agency staff assigned Alarm removed by resident Verified incorrectly Staff in orientation Other:

Bruises/skin tears/other skin/pressure ulcer: Residents skin condition and risk factors are: Good texture Fragile Prosthetic/leg rests Dry Resident altercation Bleeds easily Recent lab work/IV Prone to bruising Pressure ulcer risk factors Self-inflicting e.g. hit hand on wall Prone to ecchymosis Risk factors care planned

Care Planning and Assess. Risk assessment NOT doc. Prior to e.g. falls, skin tear, elopement, pressure ulcer, etc. Care Plan was followed as written Care Plan not followed Care Plan not current to needs

COMPLETED BY UNIT MANAGER OR DON SUMMARY OF FINDINGS: Investigation Summary and final Action Plan Completed by DON or assigned staff. Attach witness statement form as indicated.

Use codes on Incident Log. CONCLUSION: SYSTEMS FINDINGS: #_____ ACTION TAKEN: #______

IDT Review Post-Event Assessment in chart Care Plan revised

Reported to local agency: Date / Time / Method: Agency Name:____________________________

By whom: Log only Extended Investigation Initiated

DON Signature Date:

Adm. Signature Date:

Medical Director Signature Date

Page 1 of 1


WITNESS STATEMENTS – Investigation Supplement QA DOCUMENT – CONFIDENTIAL

Date of Incident: ______ Time:____ Type of Incident:___________Person interviewing witness:___________________ Resident involved: ________________________________________Rm:____________ MR#:______________ Witness Name:______________________________ Position/Relationship:______________________________ Describe what happened. What did you see? What did you hear? Who did what? Statement:___________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Witness Signature:___________________________________________ Date:___________________________________

Reviewed by: _______________________________________________ Date: __________________________________

Person Interviewing Witness:________________________ Witness Name:________________________________ Position/Relationship:______________________________ Describe what happened. What did you see? What did you hear? Who did what? Statement:___________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Witness Signature:___________________________________________ Date:___________________________________

Reviewed by: _______________________________________________ Date: __________________________________


Developed by Polaris Group Page 1 of 1 Quality Assurance/Confidential

CONFIDENTAL

MEDICATION OCCURRENCE REPORT Date of Incident: ____________________ Patient: Room: Doctor: Doctor Notified (Time and Date) Medication Involved: Signature: Diagnosis of Patient: Describe exactly what occurred (who, what, when, where, why): Report Written By: Date: Action taken to prevent reoccurrence: Nurse/Medication Aide: Date: Director of Nursing: Date: Pharmacist: Date: Copy: Director of Nursing Pharmacist


EVENT LOG (Quality Assurance/Confidential)

Timeframe________________ Indicate all that apply Indicate all that apply Indicate all that apply

INCIDENT Falls:

1. Unwitnessed-found on ground 2. During an assisted transfer 3. During self transfer from Bed 4. During self transfer from toilet 5. During self transfer from chair 6. While self ambulating 7. During assisted ambulation Behaviors: 8. Resident/Resident 9. Resident/Visitor 10. Resident/Staff 11. Elopement 12. Unaccompanied Exit 13. Self inflicted injury Medication: 14. Repeat administration 15. Wrong medication/resident 16. Wrong dose/route 17. Omission 18. IV Error 19. Transcription error

INCIDENT Skin: 20. Acquired Stage I 21. Acquired Stage II 22. Acquired Stage III 23. Acquired Stage IV 24. Skin Tear, unknown

origin 25. Skin Tear, known origin26. Bruise, unknown origin 27. Bruise, known origin 28. Burn/laceration/bite/ Other Misc. 29. Found in Hazardous

situation 30. Other 31. Risk/injury R/T

equipment

LOCATION 1. Resident Room 2. Bathroom 3. Hallway 4. Shower Room 5. Nursing Station 6. Activity Room 7. Dining Room 8. Therapy Room 9. Lobby 10. Grounds/parking lot 11. Front Exit 12. Other Exit 13. Off-premises 14. Unknown 15. Other IMMEDIATE FOLLOW-UP 1. First Aid 2. Physician orders/Tx 3. ER Visit/Hospital Admission 4. Med error – req. med. care 5. Med error – no intervention 6. Pressure relief provided 7. Environmental adjustment 8. Provided immediate protection 9. Initiated Rise Alarm

IMMEDIATE FOLLOW-UP 10. Initiated Frequent Checks 11. Lower Bed 12. Mat/Mattress by bed 13. Provide food/diversion 14. Placed in supervised area 15. Oriented to call light 16. Protective clothing - skin 17. Toileted 18. Put to bed 19. Wanderguard initiated 20. Add Enabler/trapeze 21. Review med 22. PRN med 23. Removed S/R, restraint 24. Added non slip device 25. Initiated body pillow 26. Other SYSTEM FINDINGS 1. No system issues 2. Failure of complete or accurate

Assessment/ Identification of risk factors prior to event

3. Failure to Care Plan for Risk Factors prior to event

SYSTEM FINDINGS: 4. Failure to implement Care Plan as written prior to

event 5. Failure to provide Tx/Med as ordered 6. Staff Ratio at time of event 7. Supervision of residents by Staff 8. Staff training and orientation 9. Staff compliance with procedures 10. Failed Preventive maintenance 11. Environmental factors 12. Inadequate Assessment post-event 13. Inadequate adjustment in Care Plan post-event 14. Change in Care Plan not implemented 15. Other ACTION TAKEN 1. Care plan revision/update 2. Training for involved staff 3. General staff inservice 4. Review/analysis policy/procedure 5. Staff discipline/counseling 6. Refer to QA for further analysis of possible trend 7. Protection of resident 8. Initiated abuse/neglect extended inv. 9. Other

Date Resident Name Time of Event

Day of Week

Incident Incident Location

Immediate Follow-up

System Findings

Action Taken State Agency Notified? Y/N/NA

Agency Name

Comments

DEVELOPED BY POLARIS GROUP Page 1 of 2 Developed by Polaris Group www.polaris-group.com FH17 Page 54 of 71

Date Resident Name Time of

Event Day of Week

Incident Incident Location

Immediate Follow-up

System Findings

Action Taken State Agency Notified? Y/N/NA

Agency Name

Comments

TOTALS FOR TIMEFRAME:

DEVELOPED BY POLARIS GROUP Page 2 of 2


HIGH RISK EVENT FLASH REPORT QUALITY ASSURANCE/CONFIDENTIAL

MOS/YR: ____________________

DEVELOPED BY POLARIS GROUP Page 1 of 2 Revised 2/2011

FALLS BEHAVIORS MEDICATION ERRORS Total Falls Total Behaviors Total Reported Medication errors Unwitnessed -found on ground Resident/Resident Repeat Administration During assisted transfer Resident/Visitor Wrong Medication/wrong resident During self transfer-bed Resident/Staff Wrong dose/route During self transfer/toilet Elopement Omission During self transfer/chair Unaccompanied Exit IV Error While self ambulating Self-inflicted injury Transcription During assisted ambulation Total Falls DAY OF THE WEEK – FALL DAY OF THE WEEK – BEHAVIORS MISC. Sunday Sunday Found in hazardous situation Monday Monday Other Tuesday Tuesday Risk/injury R/T equipment Wednesday Wednesday Alleged abuse/neglect complaint Thursday Thursday # reported to State Friday Friday # Substantiated Saturday Saturday LOCATION FALLS LOCATION BEHAVIORS PRESSURE ULCERS Resident Room Resident Room %Acquired %Total Bathroom Resident/visitor Total # residents w/ acquired for month Hallway Hallway Acquired Stage I Shower Room Shower Room Acquired Stage II Nursing Room Nursing Station Acquired Stage III Activity Room Activity Room Acquired Stage IV Acquired Non-stageable Dining Room Dining Room Total # residents with Pressure Ulcer Therapy Room Therapy Room Total Stage I Lobby Lobby Total Stage II Grounds/parking lot Grounds/parking lot Total Stage III Total Stage IV Front Exit Front Exit Total Non-stageable Other Exit Other Exit Total Skin Tears for month Off-premises Off-premises Skin Tears, unknown origin Unknown Unknown Skin Tears, known origin Other Other Bruises total for month Bruise, unknown origin Bruise, known origin Burn/laceration/bite/other FALLS TIME OF DAY BEHAVIORS TIME OF DAY 7a.m. – 9a.m. 7a.m. – 9a.m. Grievances 9a.m. – 11a.m. 9a.m. – 11a.m. Lost Item 11a.m. – 1p.m. 11a.m. – 1p.m. Physical Restraints 1p.m. – 3p.m. 1p.m. – 3p.m. Restrictive side rails 3p.m. – 5p.m. 3p.m. – 5p.m. 5p.m. – 7p.m. 5p.m. – 7p.m. 7p.m. – 9p.m. 7p.m. – 9p.m. 9p.m. – 11p.m. 9p.m. – 11p.m. 11p.m. – 1a.m. 11p.m. – 1a.m. 1a.m. – 3a.m. 1a.m. – 3a.m. 3a.m. – 5a.m. 3a.m. – 5a.m. 5a.m. – 7a.m. 5a.m. – 7a.m.


HIGH RISK EVENT FLASH REPORT QUALITY ASSURANCE/CONFIDENTIAL

MOS/YR: ____________________

DEVELOPED BY POLARIS GROUP Page 2 of 2 Revised 2/2011

TOTAL EVENTS BY LOCATION TOTAL TIME OF DAY TOTAL DAY OF WEEK Resident Room 7a.m. – 9a.m. Sunday Bathroom 9a.m. – 11a.m. Monday Hallway 11a.m. – 1p.m. Tuesday Shower Room 1p.m. – 3p.m. Wednesday Nursing Station 3p.m. – 5p.m. Thursday Activity Room 5p.m. – 7p.m. Friday Day Room 7p.m. – 9p.m. Saturday Dining Room 9p.m. – 11p.m. Therapy Room 11p.m. – 1a.m. TOTAL FOLLOW-UP Lobby 1a.m. – 3a.m. No injury Beauty Shop 3a.m. – 5a.m. Injury Grounds/parking Lot 5a.m. – 7a.m. First Aid Front Exit Medical Treatment Other Exit TOTAL ACTION TAKEN ER Visit Off-premises Care Plan revision/update Hospital Admission Unknown Training for involved staff Death Other General staff inservice Med error – no harm Review/analysis/policy/pro. Med error – requires medical

intervention TOTAL SYSTEM FINDINGS Staff discipline/counseling No system issues Refer to QA for further analysis Failure to complete/accurate

assessment/risk factors prior Protection of resident

Failure to care plan risk factors Initiated abuse/neglect Inv. Failure to implement care plan as

written prior event Other

Failure to provide med/tx Staff ratio at time of event SUMMARY Supervision of residents by staff Staff compliance with procedures Failed preventative maintenance Environmental factors Inadequate assess. Post event Inadequate care plan post event Change in care plan not

implemented post event

Monthly High Risk Event Review: Medical Director Date: Director of Nursing Date: Administrator Date:


EVENT REVIEW AUDIT (QA and Confidential)

Resident: Date of Event: Time: a.m./ p.m.

Location: RM#:

Type of Event: Injury: Medical Record--Appropriate Forms/ Assessments Complete: Assessment/Nurses Notes At time of Event Alert Charting Dr. Notified Family Notified

On 24 hour report Event Report Complete Contributors to Event Accurate IDT Review

Care Plan Adjusted per contributors Meds/treatment per orders/policy Other (consent, skin flow etc)

Prior to onset / Event:

Accurate and Complete Assessment with all Risk Factors Identified (Fall Risk, Skin Risk, CAAs etc per procedures)

Care Plan was based on Risk Factors?

Care Plan was implemented?

Any New Contributing Factors identified post-occurrence?

Care Plan updated to all old/new Risk Factors?

Conclusions / further follow–up: Avoidable Yes No

Action Plans/Training needs:

Signature: Date:

Page 1 of 1


Developed by Polaris Group Page 1 of 4

POTENTIAL INCIDENT/ABUSE/NEGLECT REPORT

Facility: ________________________________________________ Date of Report:_______________________

Was this incident reported to State Agency? (circle one) Yes No

Resident(s) involved in incident / abuse / neglect: (list below)

NAME DOB SEX MEDICAL RECORD #

ATTENDING PHYSICIAN

INJURED YES NO

Date of Incident: _____________ Time of Incident: _________________ Location of Incident: _______________________

Date investigation initiated: ________________ Person completing report: _____________________________________________ Investigation initiated due to: If complaint/concern made, originated from:

Injury / mark of unknown origin Pattern of incidents Person/Person Injury Report of suspected abuse Other (specify): ______________________

Person served Family member Day program/school Staff member Other (specify): __________________________

Resident Information: Diagnosis: ______________________________________________________________________________________________

Ambulatory status: _______________ ADL status: _______________ Cognitive level: ________________________________ If resident injured, describe the nature of the injury: Type of injury: ____________________________________________________________________________________________

Describe incident: _________________________________________________________________________________________

________________________________________________________________________________________________________

Effect on resident:_________________________________________________________________________________________

Follow-up re: care or treatment provided: ______________________________________________________________________

Post-incident diagnosis /resident current status: _________________________________________________________________

Date and time Administrator notified of the incident / abuse / neglect: __________________________________________________ (For incidents involving alleged abuse or serious physical injury, facility legal counsel should also be immediately notified of incident).

Which facility staff person(s) first became aware of injury or incident/abuse/neglect? ______________________________________

_________________________________________ Title: ____________________________________________________________

When did they first become aware of injury/incident/abuse/neglect? Date: ______________ Time: _________________________

List all staff persons working on the resident’s unit during the shift when the incident/injury/abuse/neglect is believed to have occurred, or who may have knowledge concerning how the injury/incident/abuse neglect occurred:

NAME ROOM # INTERVIEWED BY YOU? (If YES, date and time)

Attach copies of any statements and/or reports of interviews




If resident injury occurred, list all residents who may have knowledge about source of injury (other than injured resident):

NAME ROOM # INTERVIEWED BY YOU? (If YES, date and time)

Incident was reported: Verbally to reporter Observed by reporter Reasonably suspected

By: Resident Family Another Staff member Other: ____________________________ Type of suspected abuse:

Physical Neglect Fiduciary Abandonment Isolation

Psychological Abduction Verbal Other: _________________________________________________ Description of abuse and/or neglect: ___________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Past history of abuse with the alleged perpetrator(s)? YES NO Unknown If yes, past injuries to resident or to others? ______________________________________________________________________ When: ___________________________________________________________________________________________________ Previous threats of abuse to resident or to others: YES NO Unknown If yes, describe: ____________________________________________________________________________________________ When: ___________________________________________________________________________________________________ Suspected Abuse related change of mental status:

Loss of memory? If yes, describe: __________________________________________________________________________

Change in level of consciousness? If yes, describe: _____________________________________________________________

Is the nature/location of the injury such that it is highly unlikely to have been accidental or self-inflicted? YES NO (If YES, or if abuse or neglect is known to have occurred, calls to facility ADMIN, the Ombudsman, Local Law Enforcement and if applicable, Licensing).

Is resident capable of reporting abuse and problems with care? YES NO Explain: _______________________________________________________________________________________________ Was resident interviewed regarding injury or incident? YES NO – If NO, why not? Explain: _______________________________________________________________________________________________ If YES, give date/time of interview and person(s) interviewing resident and information provided by the resident: ______________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Person engaging in the alleged abusive behavior? ______________________________________________________________

What was the person’s mood before the incident? Typical Agitated Tired Depressed

Other: _________________________________________________________________________________________________




What caused this to happen? Environment Illness Other peer Property or equipment involved Change in routine

Other: _________________________________________________________________________________________________ Describe the events leading up to incident (antecedents): ___________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Diagram of injuries - not applicable Front View

Back View

Temporary measures initiated to prevent reoccurrence (i.e. employee suspension, room change, etc): _________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Did you review any facility records in connection with this investigation? Nurses Notes Care plan Physician orders Physician’s progress notes Prior incident reports

Other: __________________________________________________________________________________________________ (attach copies of pertinent records) Based on your investigation, is there reason to believe abuse or neglect occurred? YES NO If NO, and injury is of unknown source, state why you believe that there is no reason to believe abuse or neglect occurred: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Protective or corrective actions taken: ___________________________________________________________________________ __________________________________________________________________________________________________________ SIGNATURE OF STAFF COMPLETING REPORT:

Title: _____________________________________________________________ _____________________________________________________________

SIGNATURE OF STAFF/WITNESS:

Title: _____________________________________________________________ _____________________________________________________________

SIGNATURE OF STAFF/WITNESS:

Title: _____________________________________________________________ _____________________________________________________________




ADMINISTRATIVE STAFF TO COMPLETE: Reports made to the following: Verbal/Date Talked TO Call Made By Written/Date Sent By

Physician

Family and/or Residence

Ombudsman

Adult Protective Services

Dept. of Health Services

County Adult Protective Services Agency

Regional Center

Local Law Enforcement

ADMINISTRATOR SIGNATURE OF REVIEW: ___________________________________________ DATE: _____________

RN SIGNATURE OF REVIEW: ________________________________________________________ DATE: _____________ MD SIGNATURE OF REVIEW: _________________________________________________________________ DATE:_________________


RiskMeetingNotes

ProvidedbyPolarisGroup Page1

Attendance:______________________________________________________Date:____

Resident Name Room Number

Issue – ie wound, weight loss, fall, etc

Comments Follow-up Needed



SKIN TRACKING LOG

Name & Room # Date and time Noted

Location on Body

Type (Tear, bruise, abrasion,

pressure, etc.) STAGE TX

Order Family Notified Progress Progress Progress Date Tx

changed Resolved

date Pressure Ulcers

Admitted In house

Monthly Summary and Conclusions: Percent % Pressure Sores: ______ % in-house Pressure Sores:________

Signature _________________________________________ Date ________________________


Developed by Polaris Page 1 of 1

ENTER THE NAME AND ROOM NUMBER OF RESIDENTS DETERMINED TO BE AT HIGH NUTRITIONAL RISK. PLACE AN “X” IN THE APPROPRIATE RISK COLUMN. ENTER DOCUMENTATION DATE(s).ENTER DATE RISK MONITORING IS DISCONTINUED AS APPROPRIATE. MONTH: YEAR: UNIT/WING:

Start Date Name Room

Pres

sure

U

lcer

/Sta

sis U

lcer

Si

gnifi

cant

wei

ght

Los

s > 1

0% B

elow

IB

W

Low

Alb

umin

<3.

0

Tub

e Fe

edin

g

At R

isk

for

Deh

ydra

tion

Oth

er

Oth

er

Oth

er

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June

July

Aug

ust

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r



MONTHLY INFECTION REPORT

Month _________________ INFECTION

Antibiotic Body Site Interventions Date Resident Name Only / No Date or and Culture Nosocomial Age & Sex Room Infection Onset Organ Precautions Pathogen Outcome Yes//No Comments

Total Number of Residents (Avg. Census): _________ UTIs: ____________ GI: _________ Other: __________ Total Number Nosocomial Infections: ________ URIs:____________ Skin: _______ Nosocomial Incident Rate: _________% LRIs: ___________ Eye: ________


©2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.

Acute Care Transfer Log

You can use this tool as a worksheet for recording all acute care transfers during a month. Print more pages as needed. This tool is not necessary if you use the INTERACT Hospitalization Rate Tracking Tool, which allows you to enter the data directly into an Excel spreadsheet, and calculates rates and generates reports. A similar tracking tool is available through the Advancing Excellence Campaign in America’s Nursing Homes at www. nhqualitycampaign.org

1 Hosp = acute care hospital; H = home; O = Other location2 PAC = post-acute care (most often Medicare Part A skilled care) for rehabilitation and/or management of medical or post-surgical conditions; LTC = long-term care3 IP = admitted as an inpatient; OBS = admitted on observation status; ER = emergency room visit only with return to the facility (includes residents who die in the ambulance or ER)4 Examples of options on the above referenced Tracking Tools: Bleeding, Cellulitis, Chest Pain, CHF, COPD, Dehydration/Electrolyte Imbalance, Fall, GI (vomiting, diarrhea, pain),

Pneumonia/Respiratory Infection, Seizure, Sepsis, Shortness of Breath, UTI, Other

Resident ID

Date of Most Recent Admission to Facility

Admitted to Facility from 1 (circle)

Status on Admission2 (circle)

Date of Acute Care Transfer

Time of Transfer(circle AM or PM )

Outcome of Transfer3 (circle)

Reason for Transfer 4

/ / Hosp H O PAC LTC / /AM

PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER


PM IP OBS ER

Facility Name ___________________________________________________________________________________________________ Month /Year ____________ / _____________


©2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.

The INTERACT QI Tool is designed to help you analyze hospital transfers and identify opportunities to reduce transfers that might be preventable. Complete this tool for each or a representative sample of hospital transfers in order to conduct a root cause analysis and identify common reasons for transfers. Examining trends in these data with the INTERACT QI Summary Tool can help you focus educational and care process improvement activities.

SECTION 1: Describe Resident Characteristics

Resident ID _______________________________________________________________________________________ Age _________________

Date of most recent admission to nursing home ________ / ________ / _________

a. Major diagnoses at admission _____________________________________________________________________________________________

b. Conditions that put the resident at risk for hospital admission or readmission:

Hospitalization within the last 6 months CHF COPD Cancer, on active chemo or radiation therapy Polypharmacy (e.g. 9 or more medications) Multiple co-morbidities (e.g. CHF, COPD and DM in the same Surgical complications patient; or multiple active diagnoses) Fracture Other (describe)

c. Resident hospitalized in the past 30 days? No Yes (list dates and reasons)

d. Resident hospitalized in the past 12 months? No Yes (list dates and reasons)

SECTION 2: Describe the Acute Change in Condition and Other Non-Clinical Factors that Contributed to the Transfer

a. Date the change in condition first noticed ________ / ________ / _________

b. Briefly describe the change, symptom, sign or other factor(s) that led to the transfer and then check each item below that applies

Quality Improvement ToolFor Review of Acute Care Transfers

(continued on reverse side )


©2011 Florida Atlantic University, all rights reserved.

c. Check all that applyChange In New Symptoms or Signs Abnormal Labs or Tests Other Factors Appetite Abnormal vital signs Blood sugar Advance directive Behavior (low/high BP, high respiratory rate) CBC not in place Fluid intake Behavioral symptoms EKG Family and/or resident Function Bleeding Kidney function preference Mental status Breathing difficulty or (BUN, Creatinine) MD/NP/PA decision Pain level shortness of breath Pulse oximetry Other (describe) Skin or wound Confusion or worsening Urinalysis or urine culture Other (describe) cognitive function Venous doppler Constipation X-ray Cough Other (describe) Dizziness Fainting (syncope) Fall(s) Fever Pain Unresponsiveness Urinary symptoms or incontinence Other (describe)

SECTION 3: Describe Action(s) Taken to Evaluate and Manage the Change in Condition Prior to Transfer

a. Briefly describe how the changes in Section 2 were evaluated and managed and check each item that applies

b. Check all that applyTools Used Medical Evaluation Testing Interventions Stop and Watch Telephone only Blood tests New medication SBAR NP or PA visit EKG IV or subcutaneous fluids Care Path(s) MD visit Urinalysis and/or culture Oxygen Change in Condition Other (describe) Venous doppler Other (describe) File Cards X-ray Transfer Checklist Other (describe) Acute Care Transfer Form (or an equivalent paper or electronic version) Advance Care Planning Tools Other Structured Tool or Form (describe)

(continued)

Quality Improvement ToolFor Review of Acute Care Transfers (cont’d)


©2011 Florida Atlantic University, all rights reserved.

c. Were advance care planning or advance directives considered in evaluating / managing the change?(e.g. orders for Do Not Resuscitate (DNR), Do Not Intubate (DNI), palliative or hospice care ): No Yes

If yes, were the relevant advance directives: Modified as a result of this change in clinical condition? Already in place and documented? New as a result of this change in clinical condition?

Describe ______________________________________________________________________________________________________________

SECTION 4: Describe the Hospital Transfer

a. Date of transfer __________ /__________ /__________ Day ____________________ Time (am/pm) _______________________

b. Clinician authorizing transfer: Primary MD Covering MD NP or PA Other

c. Outcome of transfer: ED visit only Held for observation Admitted to hospital as inpatient

Hospital diagnosis(es) (if available) _________________________________________________________________________________________

d. Resident died in ED or hospital: No Yes Unknown

SECTION 5: Identify Opportunities for Improvement

a. In retrospect, does your team think this transfer might have been prevented? No Yes (check all that apply and describe below)

The new sign, symptom, or other change might have been detected earlier Changes in the resident’s condition might have been communicated better among NH staff, with MD /NP/PA, or with ER staff The condition might have been managed safely in the facility with available resources Resources were not available to manage the change in condition safely or effectively (check all that apply) On-site primary care clinician Staffing Lab or other diagnostic tests Pharmacy services Other (describe) _______________________________________________________________

Resident and family preferences for hospitalization might have been discussed earlier Advance directives and/or palliative or hospice care might have been put in place earlier Other (describe)

b. In retrospect, does your team think this resident might have been transfered sooner? No Yes (if yes, describe)

c. After review of how this change in condition was evaluated and managed, has your team identified any opportunities for improvement? No Yes (describe specific changes your team can make in your care processes and related education as a result of this review)

Name of person completing form _____________________________________________________ Date of completion _______ /_______ /_______

Quality Improvement ToolFor Review of Acute Care Transfers (cont’d)


Incident/Event QA Check Resident: _______________________________________________________ Date of Incident:___________ Type of Incident:_______________________ Reviewer:__________________________ Date performed: _______ Check all those that are complete per procedures. Comment on any areas deficient and needing follow-up. Indicate follow-up. Fall (Check if complete) _____Fall nurse’s note complete _____Family notified _____Physician notified _____Incident report complete _____24 hour report updated _____Communication Board updated _____Post-fall charting initiated _____Care Plan revised post incident _____Investigation documented _____Summary of findings and final care plan revision. ____ Reported to State if required

Comment on any incomplete steps and Follow-up:

New Pressure Ulcer ____Skin Risk tool current ____Bath skin check done by aide ____Weekly skin check done by nurse ____PU described in detail in n/n ____Family notified ____Physician notified ____Treatment orders initiated timely ____Referral to wound nurse ____Wound nurse documents all risk risk factors ____Care Plan revised ____Weekly wound flow sheet complete ____Weekly assessment complete ____ Physician notified after 2 weeks if no progress noted. ____ PU avoidable or not avoidable?

Comment on any incomplete steps and Follow-up:

Bruise ____Nurse’s note complete ____Family notified ____Physician notified ____ Incident Report complete ____ 24 hour report updated ____ Post bruise charting initiated ____ Care Plan revised to short term problem ____ If ongoing problem, interventions reviewed ____ Investigation documented with findings ____ If unknown origin, potential abuse investigation initiated and complete. ____ Follow-up documented with appropriate Reporting to state.

New Physical Restraint ____Assessment ____Doc. of alt . tried ____Physician order complete ____Family notified ____Authorization/Consent ____Restraint assessment complete ____Care Plan updated ____Referral to therapy ____If injury related restraint, documentation and incident report done. ____Quarterly assessments for continued use or reduction ____Restraint applied/released as ordered

Skin Tear ____Nurse’s note complete ____Family notified ____Physician notified ____Orders implemented ____Incident Report complete ____24 hour report updated ____Post skin charting initiated ____Care Plan revised to short term problem ____If ongoing problem, interventions reviewed ____Investigation documented with findings ____If unknown origin, potential abuse investigation initiated and complete. ____Follow-up documented with appropriate Reporting to state.

Acute change in condition _____Documentation of change in N/N _____Physician notified _____Orders implemented _____Family notified _____24 hour report updated _____Communication board updated _____IT informed _____Acute care plan initiated _____Documentation noted until resolved _____Timely labs if ordered _____Other

Other types of Incidents (e lopement, resident to resident, aspiration, etc) ____Nurse’s note complete ____Family notified ____Physician Notified ____Order implemented ____24 hour report updated ____Care Plan revised/initiated ____Incident report complete ____Investigation complete based on type of incident e.g. Wanderguard check, Alarms ____Reported to State as indicated

Abuse Investigation ____Alleged abuse reported timely ____Incident report initiated ____Abuse investigation initiated ____Witnesses interviewed and Doc. ____Identify all people in contact w/Res at t ime of event/leading up to event. ____Summary of findings ____Documentation of action taken ____Report to state as required


MANAGING RISK - Team TSI University · Managing Risk – Incident Reports & Abuse Investigations...

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