Session #8. The Key to Preventing Immediate Jeopardies. Speaker: Janine Lehman 4/17/2013 KBN:

2013 KAHCF Spring Education Conference Session #8 The Key to Preventing Immediate Jeopardies Speaker: Janine Lehman 4/17/2013 KBN: 5-0002-707-041-1217

The Key to Preventing Immediate Jeopardies Janine Lehman, R.N., RAC CT, CLNC Director of Clinical Services Wells Health Systems, Inc. What s Going on in Kentucky?!!!! 1

Recent IJ Issues Notification of Change Abuse/Neglect Elopement Revision of Care Plans Failure to Notify MD F 157 Issues Mdi Medication Errors Message left, lftno call back Meds not available Pain Medication Insulin Vital Signs Abnormal when compared to baseline Falls/Fracture Ongoing symptoms ofpain Femur Fx Neck Fx. Arm injury related to side rail entrapment 2

TOOLS AND TIPS F 157 Policy How MD/APRN/PA to be notified How to follow up with MD if APRN first notified Time Frames Follow up when leaving messages No Notification Until Acknowledgement 3

http://www.interact2.net/ 4

Care Paths 6

SBAR 7

F 223 226 Issues Wounds Assessments, treatment, monitoring i Following MD Orders Equipment and med availability Code status Verifying and following Allegations Resident to resident altercations 9

Tools and Tips F 223 226 Training Programs Wisconsin Caregiver Abuse and Neglect Prevention www.uwosh.edu/ccdet/caregiver www.ahca.org 20 10

F 323 Issues Elopement Falls related to specialty mattresses F 323 Accidents/Incidents Elopement Recent clarification re: Is it Elopement if the resident is not out of sight, ihtand followed out the doors before being returned to the facility? Determined by: Did the facility system(s) work? See Handout How OIG Surveys Elopement 14

F 323 Elopement Issues Construction/Renovation Projects Identifying Risk Following Facility Policy Head Count Search/inspection Falls and Specialty Mattresses Assessment for risks associated with specialty mattress use Siderails, vs bolsters (built in or add on), or other interventions Monitoring mattress inflation 16

Tools and Tips F 323 17

To be completed upon admission, quarterly and with any change in condition to assist with determining if Wander Risk Precautions are appropriate. Directions: Circle the appropriate score for each assessment section and total the scores in the summary score box to determine level of Wander Risk. 1 st 2 nd 3 rd 4 th 1 st 2 nd 3 rd 4 th PHYSICAL ACTIVITY HISTORY OF WANDERING 0 0 0 0 Bedfast 0 0 0 0 No known history of attempts to leave home/facility or wander 1 1 1 1 Chairfast - total assist with mobility 1 1 1 1 Occasional disorientation, no wandering or attempts to leave home/facility 2 2 2 2 Needs assist to ambulate and/or assist with wheelchair transport 2 2 2 2 Disoriented most of time, wandering without attempts to leave home/facility 3 3 3 3 Ambulatory and/or self-mobile in wheelchair 3 3 3 3 Has had one or more attempts to leave home/facility and/or wandering in the past 3 months *If score is 0-1, this section, do not proceed further with assessment. THINKING / AWARENESS COMMUNICATION 0 0 0 0 Behavior not present 0 0 0 0 Expressive, understandable, communication with others 1 1 1 1 Has occasional problem remembering where they are 2 2 2 2 Has frequent periods of altered perception and/or lack of awareness of surroundings not of recent onset 3 3 3 3 Has frequent periods of altered perception and/or lack of awareness of surroundings, of new onset MOOD AND BEHAVIOR 1 1 1 1 Usually understands, and is understood 2 2 2 2 Sometimes understands, and understood 3 3 3 3 Rarely, never understands or understood DIAGNOSIS 0 0 0 0 Complacent 0 0 0 0 No mind altering diagnosis 1 1 1 1 Occasional episodes of restlessness, or 1 1 1 1 Mild cognitive loss verbalizations of anxiety 2 2 2 2 Frequent periods of fidgeting, 2 2 2 2 Dementia with moderate cognitive repetitive physical movements, or loss verbalizations of fear, anxiety 3 3 3 3 Very agitated daily 3 3 3 3 Alzheimer s or dementia with severe cognitive impairment DECISION MAKING / MEMORY SUMMARY OF SCORE 0 0 0 0 Independent in decision making Total Review Score Key 1 1 1 1 Occasional episodes of confusion, modified independence Score 2 2 2 2 Frequent periods of confusion and mental impairment, moderately impaired 3 3 3 3 Confused most or all the time with no decision making ability, severely impaired Side 1 of 2 1 st 2 nd 3 rd 4 th 0-5 points LOW RISK 6-11 points MODERATE RISK > 12 points HIGH RISK 4/1/2013 Free template from www.brainybetty.com (copyright 2007) 36 18

WANDER RISK INFORMATION SHEET First Name: Nickname/ Name to Call: Height: Weight: Eye Color: Known Medical Conitions: WANDERER INFORMATION Middle Name: PHYSICAL DESCRIPTION Marks/Scars/Tattoos: Hair: (color, length, etc.) PHYSICAL HEALTH Last Name: Physical Limitations: it ti Hobbies, interests, etc. ADDITIONAL INFORMATION PHOTO IDENTIFICATION 4/1/2013 Free template from www.brainybetty.com (copyright 2007) INSERT FACILITY NAME AND PHONE NUMBER 39 Increased Monitoring Log Resident: Date: Start Time: Instructions: Protocol: This form is to be initiated when a High or Moderate Wander Risk resident attempts to exit the facility or a High Wander Risk resident repeatedly verbalizes that he/she is going to leave the facility. Increased monitoring will be completed for 12 hours. At the end of the 12 hour surveillance period, note whether it is indicated that the resident requires continued monitoring. After form is completed turn it in to the Director of Nursing. Monitor location and disposition of the resident every 15 minutes X 8, every 30 minutes X 12, then hourly X 4. If the resident attempts to leave the facility during these monitoring checks, a new monitoring sheet should be initiated, starting with the 15 minute checks and continue through the new 12 hour cycle. Time Resident Location Resident Disposition Staff Initials 15 min 15 min 15 min 15 min 15 min 15 min 15 min 15 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 30 min 60 min 60 min 60 min 60 min Is there a need for continued increased monitoring? YES or NO Free template from www.brainybetty.com 4/1/2013 40 Charge Nurse Signature: (copyright 2007) 20

F 280 Issues Failure to address/update careplans with resident changes, and the necessary new interventions. 22

Tools and Tips F 280 Quick care plans Update careplans/c.n.a careplans at least 2 3 times per week using the following 24 hour report sheet review Telephone orders Committee meeting findings/recommendations 23

Questions? Thank You! 24

HOW OIG SURVEYS ELOPEMENT This article is intended to provide information that will aide in understanding the survey process as it relates to elopements in Long Term Care Facilities. SUPERVISION Facilities are obligated to provide adequate supervision to residents under its care. Supervision is an intervention and a means of mitigating accidents and elopement risk. Adequacy of supervision is defined by the type and frequency, based on the individual resident s assessed needs, and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Tools or items such as personal alarms can help to monitor a resident s activities, but do not eliminate the need for adequate supervision. Adequate supervision to prevent accidents is enhanced when the facility: Accurately assesses a resident and/or the resident environment to determine whether supervision to avoid an accident/elopement is necessary; Determines that supervision of the resident was necessary and provides supervision based on the individual resident s assessed needs and the risk identified in the environment; Provides care and services, including assistive devices as necessary, to prevent avoidable accidents/elopements and to reduce the resident s risk to the extent possible; Provides adequate supervision; Incorporates processes to identify, evaluate and analyze hazards/risks; implements interventions to reduce or eliminate the hazards/risk, to the extent possible; and monitors the effectiveness of the interventions; SURVEY PROCESS Surveyors gather information through observations, interview and review of records in order to make a determination related to compliance with 483.25(h) Accidents (Tag F323). The team makes observations Of the facility s environment for any potential hazards Of the Residents Of the staff s interaction with residents Of the facility s exit doors and any alarm systems The team conducts Interview staff to determine: Aware of what resident(s) is/are at risk for elopement Aware of planned interventions to reduce a resident s risk for an avoidable accident/elopement; Aware of facility policy and/or procedures related to elopement Aware of the need to report any concerns to a supervisor The team conducts record reviews, which include the following: The RAI process

Progress notes Physician orders Nursing Plan of Care Nursing notes Other notes in record as well Assessments related to the risk of elopement If an elopement occurred identify how the facility responded This review would include an overall look at the elopement risk assessment and frequency the facility reevaluates the risk factors. Tips: OIG would: Review for the development and implementation of an individualized plan of care to address each resident s needs and goals, and to monitor the results of the planned interventions. Determine if the facility assessment is consistent with or corroborated by documentation Within the record and reflects the status of the resident for: o Behavior such as unsafe wandering, elopement, ingesting nonfood items, altercations with others; o Diagnoses that could relate to safety awareness and safe practices such as Alzheimer s and other dementias. If the resident had an accident/elopement, review the record to determine if the accident is: o The result of an order not being followed; and/or o A care need is not being addressed; and/or o A plan of care is not being implemented. o In addition, determine if the facility: (1) Investigated the cause of the accident and; (2) If indicated, implemented revised interventions to prevent additional elopement The team would review the facility s policies and procedures, staff training and may include review of staffing. Also, equipment manufacturer s information is often reviewed. Establishing and utilizing a systematic approach to resident safety may include: Identification of hazards, including inadequate supervision, and a resident s risks of potentially avoidable accidents/elopements in the resident environment; Evaluation and analysis of hazards and risks; Implementation of interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards/elopement in the environment; and Monitoring for effectiveness and modification of interventions when necessary.