Skilled Nursing Facility Abuse, Neglect Misappropriation, Injury of Unknown Source (IUS)
Investigation Guide White Paper
Background
All residents have the right to be free from abuse, neglect, and misappropriation of property. The Ohio Department of
Health and the Centers for Medicare and Medicaid Services have established regulatory guidelines for reporting and
investigating allegations or suspicions of abuse, neglect or misappropriation of resident property, and injuries of unknown
source. The goal of this white paper is to assist with skilled nursing facility members’ understanding of the overall
expectations of the reporting and investigating guidelines. All alleged violations must be reported to the administrator,
investigations begun, then reported to ODH within 24 hours, and other officials in accordance with state law. With IUS, it is
required that immediate analysis occur once an injury is discovered and immediate reporting once the IUS definition is
met. Completed investigations must be submitted to ODH electronically within 5 working days of the incident or its
discovery. Investigation form HEA1652 can be found at http://www.odh.ohio.gov/pdf/forms/hea1652.pdf. The ODH
decision tree on Abuse, Neglect, and/or Misappropriation and current instructions can be found
at: http://www.odh.ohio.gov/odhPrograms/ltc/nurhome/annc/nhann1.aspx.
Primary Federal Definitions
Abuse: the willful inflection of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm,
pain or mental anguish.
Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.
Misappropriation: the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s
belongings or money without the resident’s consent.
Injuries of unknown source: Must meet both of the following conditions to be classified as an IUS:
• The source of the injury was not observed by any person or the source of the injury could not be explained by
the resident, and
• The injury is suspicious because of the extent of the injury or the location of the injury ( e.g., the injury is located
in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time
or the incidence of injuries over time
Resident-to-Resident Altercations: An incident involving a resident who willfully inflicts injury upon another resident should
be reviewed as abuse under the guidance for 42 C.F.R. § 483.13(b) at F223. “Willful” means that the individual intended
the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish. Even though
a resident may have a cognitive impairment, he/she could still commit a willful act. However, there are instances when a
resident’s willful intent cannot be determined. In those cases, a resident-to-resident altercation should be reviewed in
comparison to the requirements at F323 – Accidents and Supervision.
PROCESS/INSTRUCTIONS for SELF REPORTING
All allegations of mistreatment, neglect, abuse, or misappropriation of resident property will be reported as required by
state and federal regulations, including an initial report within 24 hours and a final report within five working days to the
Ohio Department of Health according to current guidance and direction provided by that agency.
Injuries of unknown source shall be reported as required by state and federal regulations, including an initial reporting that
is to be made “immediately,” meaning as soon as possible, but no more that 24 hours after becoming aware of the injury.
If the facility becomes aware of a potentially reportable occurrence more that five days after the actual event, the
investigation and reporting is to be made timely related to the time of becoming aware.
• “CMS interpretation of the requirement is that ALL alleged violations involving mistreatment, neglect, or
abuse, including injuries of unknown source and misappropriation of resident property be reported
immediately to the administrator & to the State Survey & Certification agency.” Determining injuries of
unknown source must meet the CMS definition, as above
• The Incident must be reported to the state agency (ODH) immediately upon knowledge of the
incident and immediate investigation, including answers of “yes” to any of these questions:
1. Was the injury observed by any person or explained by the resident?
2. Is there a written or verbal allegation of abuse/neglect?
3. Is there reasonable suspicion that abuse/neglect may have occurred?
Further, CMS stated in a letter to ODH in November 2009 “CFR (Code of Federal Regulations) 483.13 9
(c) (2) and S&C 05-09 memo “does NOT allow providers 24 hours to investigate and then determine if an
incident is reportable.
It is permissible to submit the final with the immediate report, within twenty four hours of the occurrence as long as the
immediacy of reporting requirement is met based on the circumstances.
•
INVESTIGATION
When investigating an allegation or injury of unknown source the following need to be considered:
 Interview the resident. No matter how impaired the resident may be they may be able to tell something important
to the investigation.
 Assess the resident.
 Interview other residents that may have been in the area or have some knowledge of the situation.
 Interview family members.
 Interview staff. Check for staff members that were on duty at the time of the allegation. Interview staff members
that were scheduled before and after the allegation occurred. You can never interview too many staff members.
 Interview visitors if necessary.
 Don’t stop interviewing with a few staff members when you think you have the answer. Continue interviewing.
 Review findings with the physician if an injury has occurred to validate the story with the extent of the injury.
CONSIDERATIONS
Regulatory Considerations:
F223: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and
involuntary seclusion
F 224: deficiencies concerning mistreatment, neglect, or misappropriation of property
F226: deficiencies concerning the facility’s development and implementation of policies and procedures
F: 225: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating
residents, by a court of law, or have had a finding entered into the state nurse aide registry concerning abuse, neglect, or
misappropriation of resident property. The facility must report any knowledge of actions by a court of law against an
employee, which would indicate unfitness for service as a nurse aide or other facility staff found guilty, respectively, to the
nurse aide registry or other licensing authorities.
F157: Notification of changes: accident w/ need to notify physician, significant change, alter treatment, decision to
transfer, change in room, roommate, resident rights
Policy/Process Considerations:
The facility must develop and operationalize policies and procedures to educate all employees for screening and training,
protection of residents, and for the prevention, identification, investigation, and reporting/response of abuse, neglect,
misappropriation and injuries of unknown source. It is recommended to use the exact regulatory language in the
development of your policy and procedure.
Seven Components for facility procedures: See interpretive guidelines in F Tag 226
5. Investigation
1. Screening
6. Protection
2. Training
7. Reporting/response
3. Prevention
4. Identification
Educational Considerations: for resident, legal representative, and staff
1. Facility’s Policies and Procedures
2. Timely notification of incident according to requirements and policy
3. Current ODH self reporting methods and timeframes
4. Investigation instruction to facility management according to policy
5. All appropriate documentation according to requirements, policy and standards of practice
6. Tracking and monitoring of occurrences
7. Action plan to QA/QI process as appropriate based on patterns, trends, sentinel events
Legal/Risk Management Considerations:
• Potential for litigation
• Analyze compliance with resident care plan and effectiveness of plan after each/any occurrence
January 2011
White Paper: Choking Protocol (Dysphagia Considerations)
Historically, swallowing disorders that necessitate altered consistency diets that haven’t been consistently followed have
been an area of survey citations, up to and including immediate jeopardy scope and severity. Some of these occurrences
have resulted in resident deaths.
Choking refers to a partial and/or complete obstruction of air flow to the lungs by a foreign matter or objects such as a
random food particle that may completely occlude or significantly interrupt regulation of normal involuntary airflow.
Dysphagia is a medical term used to describe a breakdown in normal swallowing function that affects numbers of nursing
home residents. An altered consistency diet is most often prescribed due to swallowing difficulties, or dysphagia, which is
not a diagnosis but rather a symptom commonly associated with conditions such as stroke, dementia or Parkinson’s
disease.
Providers of care have struggled for many years with the debate over resident safety versus resident choice and quality of
life. Recent information also raises the concern that these at risk residents become more at risk for dehydration and
malnutrition caused by the unpalatable and visually unappealing modified dysphagia diets. (Steele C. Food for Thought:
Primum Non Nocere: The Potential for Harm in Dysphagia Intervention. Perspectives on Swallowing and Swallowing
Disorders (Dysphagia). 2006: 15: 19-23).
Management of all geriatric conditions involves some risks. No known
evaluations or interventions can guarantee that someone will not aspirate. It is important to note that many elderly
individuals with swallowing abnormalities and aspiration risk do not get aspiration pneumonia. In fact, there is evidence
that altered consistency diets may increase the risk of nutrition and hydration deficits. Thickened liquids and pureed foods
are often poorly tolerated. (Levenson, Steven. “Changing Perspectives on LTC Nutrition & Hydration.” Caring for the
Ages. September 2002, Vol. 3, No. 9, pp. 10-14. http://www.amda.com/publications/caring/september2002/nutrition.cfm)
Regulatory Considerations
• F242 §483.15(b) - Self-Determination and Participation
•
F280 §483.10(d)(3) – The resident has the right to -- unless adjudged incompetent or otherwise found to be
incapacitated under the laws of the State, participate in planning care and treatment or changes in care and
treatment.
•
F323 §483.25(h) Accidents. The facility must ensure that – (1) The resident environment remains as free from
accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to
prevent accidents.
•
F325 Nutrition – unplanned weight loss
•
F365 §483.35(d)(3) Food prepared in a form designed to meet individual needs; and
Policy/Process Considerations
Current thinking – a balance between safety and quality of life and resident choices: In deciding whether and how to
intervene for chewing and swallowing abnormalities, it is essential to take a holistic approach and look beyond the
symptoms to the underlying causes. Excessive modification of food and fluid consistency may unnecessarily decrease
quality of life and impair nutritional status by affecting appetite and reducing intake. Many factors influence whether a
swallowing abnormality eventually results in clinically significant complications such as aspiration pneumonia.
Identification of a swallowing abnormality alone does not necessarily warrant dietary restrictions or food texture
modifications. No interventions consistently prevent aspiration and no tests consistently predict who will develop
aspiration pneumonia. Source: CMS State Operations Manual Appendix PP, 483.25 Tag F325 Nutrition.
June 2013
•
Current assessment of residents’ swallowing status should be maintained
•
Documentation regarding any known diagnoses and/or medical experiences which may directly or indirectly impact
swallowing status. Diet modification history along with associated diagnostic testing results
•
Residents with dysphagia diagnosis or newly noted or worsening swallowing problems should be immediately
reported to the practitioner and referred to a Speech Language Pathologist for assessment and recommendations
•
Residents who are assessed to need food and/or fluid consistency changes
• attempt to alleviate swallowing deficiency causes as appropriate
• care planning discussions with resident and significant others
• thorough education of resident and significant others
• assure and document informed consent to treatment offered
•
Residents with swallowing difficulties who accept food and/or fluid consistency changes
• system for care-giver communication and/or resident identification to assure that appropriate food and
fluids are offered
• quality assurance system for monitoring delivery of appropriate food and fluids
•
For all residents with swallowing difficulties
• staff education regarding swallowing difficulties/dysphagia and possible dietary interventions
staff education regarding safe methods of assisting individuals with swallowing difficulties/dysphagia
staff education regarding emergency assistance for a choking individual
•
Choking/aspiration prevention policy standards for tube fed residents including safe positioning during
administration of feedings at 30-45 degrees when in bed maintained for at least 30-60 minutes post feeding
•
Focus on oral hygiene for tube fed residents and residents with swallowing difficulties/dysphagia to clear any
accumulated food particles or fluids which could be accidentally ingested/choked on
Purchase Considerations
• Pre-thickened individual single servings of nectar and honey liquid varieties
• Thickened Liquids dispenser per floor or nursing unit/medication cart
Educational Considerations
• Staff education regarding swallowing difficulties/dysphagia and possible dietary interventions
• Staff education regarding safe methods of assisting individuals with swallowing difficulties/dysphagia
• Staff education regarding emergency assistance for a choking individual
Resources
S&C 13-13-NH: Information Only: New Dining Standards of Practice Resources are Available Now, released 3,1,13
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-13.pdf
CMS State Operations Manual Appendix PP, 483.25 Tag F325 Nutrition
Pioneer Network New Dining Practice Standards, August 2011:
http://www.pioneernetwork.net/Data/Documents/NewDiningPracticeStandards.pdf
American Speech-Language-Hearing Association: http://www.asha.org/policy/type.htm
June 2013
White Paper
Use and Risks of Coumadin Therapy
Coumadin, also known as crystalline warfarin sodium, is an anticoagulant (blood thinner) that is prescribed for
residents who are at risk of forming blood clots. It is used to lower the chance of blood clots forming in the
body. Blood clots can block the flow of blood to vital organs and can cause serious health problems such as
stroke, heart attacks, or other conditions such as blood clots in the legs or lung.
Vitamin K is essential for the formation of blood clots. Residents receiving Coumadin must be monitored
closely because Coumadin inhibits the natural blood clotting process by decreasing the activity of vitamin K
thus increases the chance of bleeding.
Coumadin is essentially completely absorbed after oral administration with peak concentration generally
attained within the first 4 hours. The terminal half-life of warfarin after a single dose is approximately one week;
however the effective half-life ranges from 20-60 hours. The effects of Coumadin may become more
pronounced as effects of daily maintenance doses overlap. Routine lab work must be performed to calculate
the correct dose of Coumadin to avoid serious complications.
According to statistics, adults 60 years and older appear to demonstrate an increased sensitivity to Coumadin,
and are classified at a higher risk than younger residents. The cause of the increased sensitivity is unknown.
This White Paper on Coumadin was developed because the administration of Coumadin places such a high
risk on our frail elderly residents.
Legal/Survey Considerations
• Coumadin issues often rise to the level of immediate jeopardy survey citations and possible litigation;
• Heparin and Plavix are low risk anticoagulants and don’t require routine follow up lab work (consult with
physicians and pharmacist); a PTT may be done after administering heparin when all the lab work is
stabilized;
Regulatory Considerations
• F 281, Resident Assessment
The services provided or arranged by the facility must meet professional standards of care;
• F 309, Quality of Care
Each resident must receive and the facility must provide the necessary care and services to
attain or maintain the highest practicable physical, mental and psychosocial well being, in
accordance with the comprehensive assessment and care plan;
• F 329, Unnecessary Drugs
Each resident’s drug regimen must be free from unnecessary drugs, which includes, without adequate
monitoring.
•
•
•
F332, Medication Errors
The facility must ensure that it is free of medication error rates of 5 percent or greater
F333, Medication Errors
Residents are free of any significant medication errors.
F428, Drug Regimen Review
The drug regimen of each resident must be reviewed at least once a month by a licensed
pharmacist, and the pharmacist must report any irregularities to the attending physician, and the
director of nursing, and these reports must be acted upon.
•
•
F 502, Laboratory Services
The facility must provide or obtain laboratory services to meet the needs of the resident. The
facility is responsible for the quality and timeliness of the services;
F 508, Radiology and other Diagnostic Services:
The facility must provide or obtain radiology and other diagnostic services to meet the needs of
its residents. The facility is responsible for the quality and timeliness of the services
Policy Considerations
• Develop facility policies and procedures to include the following:
o A Quality Assurance program to monitor the administration of Coumadin and follow up lab work;
o Monitor for trends and relate those trends to physicians and the medical director;
o Include all past lab results as well as current lab results when reporting to physicians
o Various tools recommended for recording and monitoring coumadin and related lab work are
provided on the OHCA website, the link for which is listed at the end of this document;
o Policies should not suggest standard time frames for follow-up lab work; but recommend that
each resident has specific individualized orders for follow up lab work, as that is essential for
proper control
o Obtain acknowledgment of receipt for all lab work that is faxed to physicians, don’t assume it
was received;
• Care plan for increased risk of bleeding for residents receiving Coumadin, as well as aspirin and/or
Plavix, with or without Coumadin.
Educational Considerations
• Educate all facility staff who provide direct resident care;
• Educate staff, residents and families about the effects of Coumadin and include the following:
o Monitor for, and report at once to the physician any signs or symptoms of bleeding and/or
unusual bruising;
 Teach direct care staff/STNAs about signs or symptoms of bleeding and/or unusual
bruising;
o Monitor for medications that interact with Coumadin;
o Be aware of certain foods that may affect Coumadin;
o A number of OTC medications and Herbals may interact with Coumadin and if being
administered, should be discussed with physician.
• Administrative staff must continually monitor the Quality Assurance program to be sure that the
program is followed;
• Monitor for increased bleeding or bruising anytime Coumadin is started or stopped;
Purchasing Considerations
• ProTime and INRatio portable units are approved for professional and home use allowing healthcare
providers immediate INR test values resulting in improved care. The CoaguChek S is available for
professional use only. Real-time results allow immediate counseling, education and treatment without
the delay of traditional lab testing.
• Consider the approximate cost of portable units: INR = $2700; Protime = $1700; and CoaguCheks =
$1300;
• Portable units are sensitive to heat and cold;
• Portable unit strips are very expensive and can range from $7.00 and more per strip;
• Consider portable units upon discharge for home use;
• To access information about portable units go to
http://www.ptinr.com/data/templates/article.aspx?z=5&articleid=234&u=patient&ur=true
OHCA website link to Coumadin White paper and related materials: http://www.ohca.org/content/view/409/
December 8, 2006,
updated August 2007
White Paper
Electronic Health Records
Summary
The health record is the legal business record for a healthcare organization. As such, it must be maintained in a manner
that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. The
standards may vary based on practice setting, state statutes, and applicable case law. Many of the guidelines that
originally applied to paper-based health records translate to documentation in electronic health records (EHRs).
Legal/Survey Considerations
Health records are business records that can be used as testimony in legal proceedings. A health record must meet
certain standards in order to be admissible in court and not be considered hearsay. Rules of evidence for business
records, include that they are documented and kept in the normal course of business, made at or near the time of the
matter recorded by a person within the business with knowledge of the events, conditions, opinions, or diagnoses
appearing in it. A carefully designed electronic health record that meets the requirements of a legal health record is an
effective strategy to minimize a healthcare organization’s risk and liability. For these reasons it is recommended that An
attorney should review policies related to legal documentation issues to ensure adherence to the most current standards
and case law. Electronic health records systems must be set up to protect records from loss, destruction or unauthorized
use. In addition they must be systemically organized, complete, accurately documented, readily accessible and
maintained in accordance with acceptable standards of professional practice.
Regulatory Considerations
Nursing facilities are prohibited from violating the confidentiality of “personal and medical records, and the right to approve
or refuse the release of these records to any individual outside the home, except in the case of transfer to another home,
hospital, or health care system, as required by law or rule, or as required by a third-party payment contract.” Revised
Code § 3721.13(A)(10). Pursuant to Ohio Administrative Code § 3701-17-19(C), the records that a nursing home is
required to maintain may be maintained in electronic format. According to Revised Code § 3701.75(B) health care records
may be authenticated by electronic signature if the following apply:
(1) The entity adopts a policy that permits the use of electronic signatures on electronic records;
(2) The electronic signature system utilizes either a two level access control mechanism that assigns a unique identifier to
each user or a biometric access control device;
(3) The entity takes steps to safeguard against unauthorized access to the system and forgery of electronic signatures;
(4) The system includes a process to verify that the individual affixing the electronic signature has received the contents of
the entry and determined that the entry contains what the individual intended; and
(5) The policy must include: (a) a procedure by which each user of the system must certify in writing that the user will
follow the confidentiality and security policies maintained by the entity for the system; (b) penalties for misusing the
system; (c) training for all users of the system that includes an explanation of the appropriate use of the system and
the consequences for not complying with the entity’s confidentiality and security policies. Revised Code § 3701.75.
An electronic signature for health records is defined as any of the following: “(a) a code consisting of a combination of
letters, numbers, characters, or symbols that is adopted or executed by an individual as that individual’s electronic
signature; (b) a computer-generated signature code created for an individual; (c) an electronic image of an individual’s
handwritten signature created by using a pen computer.” 3701.75(A)(2).
Policy/Procedure Considerations
Develop facility policies and procedures to include the
following:
o Definition of Legal Record
 What documents in EHR are part of legal
medical record
 Resident info versus administrative info
o Viewing
 What can be viewed?
 Procedures for resident viewing
o
1
 Procedures for viewing by physicians,
surveyors, pharmacist, consultants, etc.
 Notice of electronic documentation
 Temporary logins
 Access only for those who would have
access to paper record
Printing
 Who can print? When?
 What is done when printed for reference
only
 Continuity of care
 Response to subpoena or court order or
oversight
 Valid release of information
o Downtime and disaster recovery
 Documentation process during downtime
 Disaster planning
 Recovery process
o Storage and retention
 Method
 Retention requirements
 Back up procedures
 Access procedures for archived records,
change in ownership
o Purging and destruction
o Training
 All staff that access the medical record
 Include everyone who needs to view as
well as those who enter data
 Review policies and procedures in addition
to application use
 Inservice staff regularly on policies and
procedures, monitor compliance
o Implementation
o
o
o
o
o
o
o
o
o
o
o
o
o
 Consider implementing with controlled
volume, i.e., one unit
 Determine date to discontinue routine
printing
Auditing
 Monitor completion and accuracy of
documentation
 Frequent audits initially then ongoing
periodic audits
Documentation Procedures/Principles
Authentication of entries
Electronic Signatures
Cut, Copy, Paste functionality
Corrections, errors, amendments, late entries
Retraction, Resequencing and Reassignment
Version management
Record Content
Managing data from other facilities
Decision support
Access control
Data integrity (access, audit trail and security)
 Passwords
 Staff access versus other access
Educational Considerations
• Classes are most efficient, department meetings may be an alternative
• One-on-one training can focus at the provider's level of skill but is much more labor intensive.
• Training session are recommended to be brief (10 to 30 minutes) and focused on exactly what providers need to
know to use the system and understand any work flow and policy changes.
• Trainers should have flexible schedules to allow informal support for a period following going live.
• Training super-users as trainers and to provide go-live support spreads training and support over a broader base
and closer to end users. Checklists should be used to reduce the risk of inconsistency when multiple trainers are
used.
• Use of video, CD-ROM, or Web-based training methods may be good training adjuncts
• Include screen shots in handouts or guides
• Providers should sign confidentiality agreements as part of the training process.
• If documents are to be signed in one system (e. g., an electronic signature module) and transferred to another
system (e. g., the electronic health record), directions must be clear about where to sign documents electronically.
• If there are multiple electronic signature applications in the facility and the signing conventions differ, training must
address the issue so distinctions in procedure can be pointed out to clinicians.
• Develop competency assessments to evaluate user knowledge and identify additional training needs.
References/Resources
• The American Health Information Management Assoc – LTC Health Information Practice & Documentation
Guidelines: http://www.ahima.org/resources/infocenter/ltc/guidelines.aspx
• Health Policy Institute of Ohio, Assessing Health Information Technology in Ohio:
http://www.healthpolicyohio.org.
• CMS’s RAI MDS 3.0 Manual, Chapter 2, Section 2.4, “Responsibilities of Nursing Homes for Reproducing and
Maintaining Assessments”: http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp
• Ohio Department of Health, Ohio Administrative Code, Chapter 3701-17, Nursing Homes and Residential Care
Facilities (Licensure Rules) http://www.odh.state/oh/us/rules/final/chap17/fr17_1st.htm
• Ohio Revised Code (ORC) 3701.75, “Electronic Signatures”
• Ohio Administrative Code (OAC) 3701-17-13(B)(3) “Electronic signatures used to authenticate electronic records.”
• Guidance to Surveyors of Long Term Care Facilities, Appendix pp, F514, Clinical Records
www.cms.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
• Comprehensive Health IT Implementation Toolkit, by Stratis Health
www.stratishealth.org/expertise/healthit/nursinghomes/nhtoolkit.html
• CMS Survey and Certification (S&C-05-14) Letter, “Electronic Signature Guidance Clarification”
2
White Paper
Fall Reduction and Injury Mitigation
The Ohio Health Care Association promotes and encourages member facilities’ proactive endeavors to establish
environments and cultures of safety for their residents while promoting residents’ independence, dignity, autonomy and
freedom of choice.
Background: National statistics suggest that up to 50% of nursing home residents fall each year, with approximately 1.5
falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital
admission and/or fractures. Falls and resulting injuries are commonly due to factors related to new admission to the
facility, medications, hypotension, and internal needs or motivations such as toileting, cognitive deficits leading to poor
decision making and other disease processes. Historically, facilities often utilized restraints, or restrictive devices or
approaches in their efforts to protect residents from injury. Moreover, restraint use may constitute an accident hazard, as
they have been found in some cases to increase the incidence of falls or head trauma due to falls and other accidents
(e.g. strangulation, entrapment). Additionally, residents who are restrained may face a loss of autonomy, dignity and selfrespect, and may show symptoms of withdrawal, depression, or reduced social contact. In effect, restraints can reduce
independence,
functional
capacity,
and
quality
of
life
(ODH
Restraint
Use
Guidelines
2/07
http://www.odh.ohio.gov/ASSETS/26E1A473D212453F906472770E455CDF/restraintguides.pdf). Restraint reduction and
elimination efforts over the years have occurred successfully without significant increases in injuries to residents,
according to MDS data and national studies.
Nursing facilities must proactively assess and thoroughly plan residents’ care and treatment, individualizing the plan to
meet the physical, mental and psychosocial needs of each resident. When working to reduce or minimize resident falls
and injuries, the facility must attempt to identify the factors which may place the resident at risk for falls. Interventions
must then be developed that can be reasonably expected to minimize each identified risk. Such approaches should
include, but not be limited to: medication issues, therapy and restorative nursing needs, functional supports and
environmental enhancements.
Considerations
This guide is intended to provide nursing facilities a host of resources to improve services to residents focusing on
proactive strategies and interventions to reduce resident falls and injuries from falls. Fall reduction and injury mitigation is
the responsibility of the entire staff and should never rest on only a few individuals.
1. Regulatory Considerations
• Risk of higher level citations, including actual harm and immediate jeopardy
•
F323 Accidents and Supervision - 483.25(h) & (h)(2)
•
The lack of a medical symptom for the use of a restraint may be cited at 42CFR 483.13(a) [F221,
Restraints].
•
Other potential areas for related citation: F272: Comprehensive assessments, F281, Services
provided meet professional standards, F353, Sufficient staff, F521, Quality Assessment/Assurance
•
Provide a safe environment, adequate supervision and assistive devices to prevent accidents
•
Identifying, evaluating and analyzing hazards and risks
•
Implementing interventions to reduce identified hazards and risks
•
Monitoring for effectiveness and modifying interventions when necessary
•
Quality measures / Quality Indicators / public reporting
2. Legal / Risk Management Considerations
• Potential for litigation with serious falls/injuries/death
• Analyze compliance with resident care plan and effectiveness of plan after each/any occurrence
• Consider a method to establish some baseline understanding that not all falls, accidents are preventable,
such as discussion before or on admission about inherent risks – OHCA video – “A Time of Transition”
• Facilities’ CQI/QA programs must include fall reduction and analysis components
3. Policy/Process Considerations
• Establish your facility’s mission / values related to this issue
• Establish facility’s fall management process
• Fall assessment – tools, timing, resident history
• Care planning
• Fall taxonomy of proactive interventions by categories – options & ideas
• Proactive interventions must address each identified risk factor for the individual
• Implementation and monitoring that interventions are in place
• Monitoring effectiveness of interventions and modifying them as necessary
• Resources – supplies & equipment
• Standards of practice
• Communication / education of POC to resident, family, staff and as a part of discharge planning
• Fall assessment and treatment
• Notification of necessary parties
•
Medical record documentation: fall summary in nursing notes to include all essential details
•
Investigation / root cause analysis process
• Who should be included
 physician
 pharmacist
 medical specialists
▪ nursing
▪ therapies/restorative
▪ activities
▪ maintenance/housekeeping
▪ administration
▪ dietary
• What topics need to be considered
 medical issues, including delirium (acute UTI, pneumonia), and chronic conditions
 medications
 environmental factors, equipment
 situational factors (what, when, where, circumstances)
 cognitive functional status
• Data collection / analysis
• Tracking / trending
•
Fall oversight / management committee – investigations & follow up, tracking & trending
•
Tools/forms: investigation investigative summary Falls Medication Review & drug listing
4. Educational Considerations
•
All staff regarding the mission/philosophy about falls, accidents and their roles and responsibilities
o Policies / Procedures
o Assessment, including resident history and care planning and implementation
o Post occurrence assessment/treatment and investigation
o Notification
o Documentation in the medical record
o Tracking / trending
o QI/QM / public reporting
Additional Information
ODH Fall Decision Tree www.odh.ohio.gov/ASSETS/9D79D9DA64AB41A6AFC68FB06714CF18/Falls.pdf
ODH TAP Falls Prevention Performance Improvement Project (September 2006)
ODH Restraint Guidelines www.odh.ohio.gov/ASSETS/26E1A473D212453F906472770E455CDF/restraintguides.pdf
CDC Falls Prevention www.cdc.gov/HomeandRecreationalSafety/Falls/index.html
Falls Injury Mitigation Manual www.ohca.org/uploads/news/Falls_Manual.pdf
August 2007
Stop and Watch
Early Warning Tool
If you have identified a change while caring for or observing a
resident, please circle the change and notify a nurse. Either give the
nurse a copy of this tool or review it with her/him as soon as you can.
S
T
O
P
Seems different than usual
Talks or communicates less
Overall needs more help
Pain – new or worsening; Participated less in activities
a
n
d
Ate less
No bowel movement in 3 days; or diarrhea
Drank less
W
A
T
C
H
Weight change
Agitated or nervous more than usual
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, toileting more than usual
Name of Resident
Your Name
Reported to
Date and Time (am/pm)
Nurse Response
Date and Time (am/pm)
Nurse’s Name
©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.
Advance Care Planning
Communication Guide: Overview
The INTERACT Advance Care Planning Communication Guide is designed to
assist health professionals who work in nursing homes to initiate and carry out
conversations with residents and their families about goals of care and preferences
at the time of admission, at regular intervals, and when there has been a decline
in health status.
The Guide can be useful for education, including role-playing exercises and
simulation training.
Communicating about advance care planning and
end-of-life care involves all facility staff
• Physicians must communicate with residents and families about advance directives,
but all staff need to be able to communicate about goals of care, preferences,
and end-of-life care
This Guide should therefore be useful for:
• Nursing staff
• Primary care physicians, nurse practitioners, and physician assistants
• Social workers and social work designees
• Administrators and others who discuss goals of care with residents and family
The Guide may be helpful in discussions on:
• Advance Directives – such as a Durable Power of Attorney for Health Care document,
Living Will, and POLST and other similar directives
• Plans for care when a sudden, life-threatening condition is diagnosed – such as a stroke,
heart attack, pneumonia, or cancer
• Plans for care when a resident’s health is gradually deteriorating – such as progression
of Alzheimer’s disease or other dementia; weight loss without an obvious medical cause;
and worsening of congestive heart failure, kidney failure, or chronic lung disease
• Considering a palliative or comfort care plan or enrolling in a hospice program
©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.
Advance Care Planning Communication Guide
Part 1: Tips for Starting & Conducting the Conversation
Set the Stage
1.
2.
3.
4.
5.
6.
7.
Get the facts – understand the resident’s conditions and prognosis.
Choose a private environment.
Determine an agenda for the meeting and who should be present.
Allow adequate time – usually these discussions take at least 30 minutes.
Turn cell phone or beeper to vibrate to avoid interruptions and demonstrate full attention.
If the resident is involved, sit at eye level with her or him.
Have tissues available.
Initiate the Discussion
1. Describe the purpose of the meeting.
2. Identify whether the resident wants or already has a spokesperson and who it is.
3. Ask what the resident and/or family understand about advance care planning.
4. Ask about their goals for care
• Most nursing home residents and their families are more concerned about comfort than
life prolongation. This opens the door to discuss palliative care and comfort care plans.
• Attempt to understand underlying rationale for the goals (i.e. “ I’ve lived long enough,
now I’m ready to meet God,” or “I want to keep on living until my granddaughter graduates
college next spring.”). This provides insight into specific decisions that are made.
Initiate the Discussion
1. Use simple language.
2. Briefly discuss:
• Cardiopulmonary arrest and CPR*
• Artificial Hydration/Nutrition (tube feeding**)
• Palliative care, comfort care orders*** and hospice if appropriate.
Cardiopulmonary Arrest and CPR*
1. Initiate discussion of Cardiopulmonary Resuscitation (CPR).
• e.g. “Sometimes when peoples’ hearts stop, doctors and nurses try to delay the dying process… have you considered whether you would want this or not?”
2. Discuss some facts:
• Cardiopulmonary arrest is the final common pathway for everyone when they die.
Not all deaths should involve CPR.
• The possibility of surviving CPR in a nursing home is very low, and CPR often results in
broken ribs and the need for a respirator (‘breathing machine’) in an intensive care unit.
• A request to not perform CPR (a Do Not Resuscitate (DNR) Order) does not alter care –
it only prevents CPR if the resident is found without a heart beat or not breathing.
*… See INTERACT Education on CPR
**… See INTERACT Education on Tube Feeding
***… See INTERACT Comfort Care Orders
(continued)
©2011 Florida Atlantic University, all rights reserved.
Advance Care Planning Communication Guide
Part 1: Tips for Starting & Conducting the Conversation
(continued)
Artificial Hydration/Nutrition (tubefeeding)**
1. Initiate discussion of feeding tubes:
• “Many nursing home residents gradually lose the ability to eat, drink, and swallow.
In this situation a tube can be placed in the stomach to provide water and nutrition.
Have you considered whether you would want this or not?”
2. Discuss some facts:
• Feeding tubes have not been shown to prevent pneumonia or prolong life for most
nursing home residents.
• Placement of a tube requires minor surgery, and can have some complications.
• A request to not place a tube does not alter care – residents will be provided oral
fluid and nourishment as long as it is comforting for them.
• People who do not get feeding tubes generally gradually slip into a comfortable
coma within a few days and die comfortably.
Palliative Care and Comfort Care Orders
1. Review overall goals for care and the importance of comfort and quality of life
regardless of advance directives
2. If the goal of care is comfort:
• Offer to provide and review educational materials on palliative care.
• Describe examples of comfort care orders.***
• Discuss limiting hospitalization only for the purpose of improving comfort,
not to prolong life.
• If appropriate, provide information about palliative and/or hospice care.
End the Discussion
1. Ask: “Do you have any questions?”
2. Emphasize that the role of the nursing home is to ALWAYS provide comfort no matter
what the goals of care.
3. Offer to have a follow-up meeting if indicated.
4. Stand – an effective way to end the conversation.
**… See INTERACT Education on Tube Feeding
***… See INTERACT Comfort Care Orders
©2011 Florida Atlantic University, all rights reserved.
Advance Care Planning Communication Guide
Part 2: Communication Tips
Tips
Examples
Establish Trust
Encourage residents
and families to talk
“ Tell me what you understand about your illness.”
“Help me get to know you better – tell me about your life before you came
to this nursing home.”
“How are you coping with your illness?”
Recognize resident and
family concerns, but
do not put down other
health care providers
“I understand that you didn’t feel heard by other doctors/nurses.
I’d like to make sure you have a chance to voice all of your concerns.”
“It sounds like Dr. X left you very hopeful for a cure. I’m sure he really cares for you, and
it would have been wonderful if things would have gone as well as he/she wished.”
Acknowledge mistakes
“You are absolutely right. Four days was too long to wait for that [test or procedure].”
Be humble
“I really appreciate what you have shared with me about the medication
we prescribed. It is clear that it is not right for you.”
Demonstrate respect
“I am so impressed by how involved you have been with your [relative] throughout
this illness. I can tell how much you love her/him.”
Do not force decisions
“ We’ve just had a very difficult conversation, and you and your family have a lot to
think about. Let’s schedule another meeting and see how you feel about things then.”
Attend to Emotions
Attend to the emotion
“ Is talking about these issues difficult for you? Making these decisions is not easy.”
Identify loss
“ I bet it’s hard to imagine life without your [relative] – I can see how close you
are to her/him.”
Legitimize feelings
“ It’s quite common for someone in your situation to have a hard time making
these decisions – it can feel like an enormous responsibility.”
“ Of course talking about this makes you feel sad – it wouldn’t be normal if it didn’t.”
Explore
“ You’ve just told me you feel scared. Can you tell me more about what scares you most?”
Offer support
“ No matter what the road holds ahead, I’m going to be there with you.”
Communicate Hope
Hope for the best, but
prepare for the worst
“ Have you thought about what might happen if things don’t go as you wish?
Sometimes having
a plan to prepare for the worst makes it easier to focus on what you hope for most.”
Reframe hope
“ I know you hope your illness will improve. Are there other goals you want to focus on?”
Focus on the
positive
“ Some treatments are really not going to help and may make you feel worse or
uncomfortable. But there are a lot of things we can do to help you – let’s focus
on those.”
“ What sorts of things are left undone for you? Let’s talk about how we might be able
to make these happen.”
©2011 Florida Atlantic University, all rights reserved.
Advance Care Planning Communication Guide
Part 3: Helpful Language for Discussing End-of-Life Care
Issue
Helpful Language
Identify other
decision makers
“Is there anyone you rely on to make important decisions?”
Define goals for care
“What do you hope for most over the next few months?”
“Is there anything that you are afraid of?”
Reframe goals
“I wish we could guarantee you will be alive for your [event], but unfortunately
we can’t. Perhaps we can work on a letter to read on that day, so people will know
you are there in spirit in case you cannot be there.”
Identify needs for care?
“What types of treatments do you think will help you the most?”
Summarize and link
goals with care needs
“I think I understand that your main goals are to be comfortable and alert enough
to spend time with your family. We have several ways we can help you.”
Introduce palliative
or comfort care
and/or hospice
“One of the best ways to meet your needs would be a comfort care plan.”
“One of the best ways to give you help is a program called hospice. The hospice
program can provide extra support and the hospice has a lot of experience in
caring for seriously ill people.”
Acknowledge
response
“You seem surprised to learn how sick you are.”
“I can see it is not easy for you to talk about end-of-life care.”
Empathize
“I can imagine how hard this is for all of you to talk about – you care about
each other so much.”
Explore concerns
“Tell me what is upsetting you the most.”
Explain comfort care
or hospice goals
“Comfort or hospice care does not help people die sooner – it helps people die naturally.”
“Comfort and hospice care helps people live as well as they can for as long as they can.”
Reassure
“The goal of comfort and hospice care is to improve your quality of life as much
as possible for whatever time you have left.”
“Comfort and hospice care can help you and your family make the most of the time
you have left.”
Reinforce
commitment
to care
“Why don’t you think this over? I think comfort or hospice care is the best choice
for you right now, but the decision is yours. You know we will continue to care for
you whatever you decide.”
©2011 Florida Atlantic University, all rights reserved.
Advance Care Planning Communication Guide
Part 4: The Resident or Family Who Want Everything Done
Resident/Family Concern
How They Say It
How You Can Respond
Abandonment
“Don’t give up on me.”
“What worries you the most?”
Fear
“Keep trying for me.”
“What are you most afraid of ? ”
Anxiety
“I don’t want to leave my family.”
“What does your doctor say
about your condition? ”
Depression
“I’m scared of dying.”
“What is the most frightening to you ? ”
Incomplete
Understanding
“I do not really understand
how sick I am.”
“What are your most important goals ? ”
Wanting reassurance
that best medical care
has been given
“Do everything you think
is worthwhile.”
“What is your understanding
of your condition? ”
Wanting reassurance
that all possible
life-prolonging
treatment is given
“Don’t leave any stone unturned.”
“I really want every possible
treatment that has a chance
of helping me live longer.”
“I will go through anything,
regardless of how hard it is.”
“What have others told you about
what is going on with your illness?”
“What have they said the impact
of these treatments would be?”
“Tell me more of what you mean
by ’everything’ ?”
Vitalism
“I value every moment in life,
regardless of the pain and
suffering (which has important
meaning for me).”
“Does your religion (faith) provide
any guidance in these matters? ”
Faith in God’s Will
“I will leave my fate in God’s
hands; I am hoping for a miracle;
only He can decide when it is
time to stop.”
“How might we know when God
thinks it is your time? ”
Differing perceptions
“I cannot bear the thought
of leaving my children
(wife/husband).”
“How is your family handling this? ”
Children or dependents
“My family is only after my
money.”
“I don’t want to bother my
children with all of this.”
“Have you made plans for your
children (other dependents)?”
“Have you discussed who will make
decisions for you if you cannot?”
“Have you completed a will?”
©2011 Florida Atlantic University, all rights reserved.
Advance Care Planning Communication Guide
Sources of Information
References
This guide contains information adapted from the following sources:
1. “The Palliative Response – Sharing the Bad News,”
the Birmingham/Atlanta VA Geriatric Research,
Education and Clinical Center
2.Tulsky, JA. Beyond Advance Directives –
Importance of Communication Skills at the End of Life.
JAMA 2005; 294:359-365.
3.Casarett, DJ and Quill, TE. “I’m Not Ready for Hospice”:
Strategies for Timely and Effective Hospice Discussions.
Ann Intern Med 2007; 146:443-449.
4.Quill, TE, Arnold, R, and Back, AL.
Discussing Treatment Preferences with Patients Who Want “Everything.”
Ann Intern Med 2009; 151:345-349.
Additional Resources for Staff and Families
(available free on the internet)
1.American Association for Retired Persons
2.The Coalition for Compassionate Care
3.The Conversation Project
4.Closure.org
5.Caring Connections of the National
Hospice and Palliative Care Organization
©2011 Florida Atlantic University, all rights reserved.
Change in Condition: When to report to the MD/NP/PA
Immediate Notification
Any symptom, sign or apparent discomfort that is:
• Acute or Sudden in onset, and:
• A Marked Change (i.e. more severe) in relation to usual symptoms and signs, or
• Unrelieved by measures already prescribed
Non-Immediate Notification
• New or worsening symptoms that do not meet above criteria
This guidance is adapted from: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003; and
Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996
©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.
Vital Signs (report why vital signs were taken)
Vital Sign
Report Immediately *
Report on Next Work Day
Blood Pressure
Pulse
Respiratory Rate
Temperature
• Systolic BP > 200 mmHg or < 90 mmHg
• Diastolic BP > 115 mmHg
• Resting pulse > 100, < 50
• Respirations > 28, < 10/minute
• Oral temp > 100.5 F
• Oxygen saturation < 90%
• Diastolic BP > 90 mmHg
• New irregular pulse
Weight Loss
• New onset of anorexia with or without weight loss
• 5% or more within 30 days
• 10% or more within 6 months
Weight Gain
• > 5 lbs in one week in resident with
- CHF
- chronic renal failure
- other volume overload state
* Unless these values are stable and known by the primary care clinician
©2011 Florida Atlantic University, all rights reserved.
Laboratory Tests/Diagnostic Procedures
(report why the test or procedure was done)
Test/Procedure
Report Immediately *
Complete Blood Count
• WBC > 14,000
• Hemoglobin (Hb) < 8
Chemistry
• Blood/urea/nitrogen (BUN) > 60 mg/dl
• Calcium (Ca) > 12.5 mg/dl
• Potassium (K) < 3.0, > 6.0 mg/dl
• Sodium (Na) < 125, > 155 mg/dl
• Blood glucose > 300 mg/dl or < 70 mg/dl (diabetic)
• Glucose consistently
> 200 mg/dl
• Hb A1c (any value)
• Albumin (any value)
• Bilirubin (any value)
Consult Reports
Consultant report recommending immediate action
or changes in management
Routine consultant report recommending routine
action or changes in patient’s management
Drug Levels
Levels above therapeutic range of any drug
(hold next dose )
Any therapeutic or low level
INR (International
Normalized Ratio)
• INR > 6 IUs (hold warfarin)
• INR 3-6 IUs (hold warfarin)
• PT (in seconds) 2x control (hold warfarin)
Urinalysis
Abnormal result in resident with signs and symptoms
possibly related to urinary tract infection or urosepsis (e.g.
fever, burning sensation, pain in suprapubic or flank area)
Abnormal result in resident with no signs or symptoms
Urine Culture
>100,000 colony count with a urinary pathogen
with symptoms
Any growth with no symptoms
X-ray
New or unsuspected finding
(e.g. fracture, pneumonia, CHF)
Old or long-standing finding, no change
* Unless these values are stable and known by the primary care clinician
Report on Next Work Day
• Hematocrit < 24
• Platelets < 50,000
WBC > 10,000 without symptoms or fever
• Cholesterol (any value)
• Triglycerides (any value)
• Other chemistry values
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms A’s
Symptom or Sign
Immediate
Non-Immediate
Abdominal Pain 1
Abrupt onset severe pain or distention, OR
with fever, vomiting
Moderate diffuse or localized pain, unrelieved
by antacids or laxatives
Abdominal Distention1
Rapid onset, OR presence of marked tenderness,
fever, vomiting, GI bleeding
Progressive or persistent distension not
associated with symptoms
Abdominal Discomfort 1
(e.g., bloating, cramps, etc…)
Associated with fever, continuous GI bleeding,
or other acute symptoms
Persistent discomfort not associated with
other acute symptoms
Abrasion
Accompanied by significant pain or bleeding
If bleeding continues or if associated with
evidence of local infection
Agitation or other
Behavioral Symptoms 2
Abrupt onset of significant change from usual,
OR associated with fever or new onset abnormal
neurological signs
Continued progression or persistence of symptoms
Appetite, Diminished
N/A
Significant decline in food and fluid intake in resident
with marginal hydration and nutritional status
Asthma
Acute episode with wheezing, dyspnea,
or respiratory distress
Self-limited episode that was more extensive or
less responsive to treatment than the usual
1 See INTERACT GI Symptoms Care Path 2 See INTERACT Change in Behavior Care Path
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms B’s
Symptom or Sign
Immediate
Non-Immediate
Back, injuries
and complaints
Abrupt onset of severe pain secondary to fall or injury,
OR pain with new abnormal neurological signs
Persistent back pain not responding to existing
or progressive orders
Bleeding, rectal
(melena)
Persistent, or accompanied by diaphoresis, tachycardia,
significant orthostatic BP drop
Recent self-limited bleeding: black stool or melena
without change in vital signs; stools positive for occult
blood on routine testing
Blisters
Secondary to any burn more than a minor one
New onset large tense blisters with fever
Burns
Any burn other than a minor first degree burn
with no significant pain
Minor first degree burn in past twenty-four hours
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms C’s
Symptom or Sign
Immediate
Non-Immediate
Chest pain, pressure
or tightness
New or abrupt onset, unrelieved by current medications,
OR accompanied by diaphoresis, change in vital signs or
new EKG changes
Relieved by antacids or nitroglycerin, without other
symptoms, but recurring more often than usual
Common cold
With marked respiratory distress, severe cough,
or T > 100.5 F
Change in color of sputum or phlegm; persistent
need for symptom relief
Complaint, medical,
by family or patient
Demand to speak to a physician or have a medical
assessment without delay
Any persistent or recurrent complaint that might
need a physician’s attention
Confusion1
Abrupt significant change from usual, or a change
in level of consciousness
Abrupt persistent change from usual with no other
significant symptoms
Consciousness,
altered 1
Sudden change in level of consciousness
or responsiveness
Gradual but persistent recent change in level
of consciousness or responsiveness
Constipation
Severe abdominal pain, rigid abdomen,
absent bowel sounds
< 1 BM in a week
Contusions
Accompanied by significant pain or bleeding
Associated with a recent fall with no other complications
Cough 2
Associated with blood in sputum, new sputum
production, fever or respiratory distress
New or recent onset of persistent or nocturnal cough,
causing discomfort or disturbing sleep
1 See INTERACT Acute Mental Status Change Care Path 2 See INTERACT Symptoms of Lower Respiratory Illness Care Path
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms D’s
Symptom or Sign
Immediate
Non-Immediate
Depressed affect
(see ‘Suicide, potential’ )
Acute suicidal ideation
Recent onset of significant mood decline,
with anorexia, crying, and sleeplessness
Diabetes, poorly
controlled
Any diabetic with altered mental status, or an acute
infection, OR hypoglycemic episode in someone
on hypoglycemic medication or not responding to
additional glucose;
Glucose > 300 or < 70 mg/dl
Usually stable diabetic with change in oral intake,
thirst, or urination, fluctuating or rising blood sugars
Diarrhea1
Acute onset of 3 or more episodes of loose stools
Persistent multiple loose with stable vital signs
Dizziness or
unsteadiness
Abrupt onset, with slurred speech, or other focal
neurological findings
Minor but persistent change over past 24 hours
from usual pattern
Dyspnea 2
(shortness of breath)
Acute onset of change from usual pattern, OR with chest
pain, labored respirations, or unstable vital signs
Recent intermittent change from usual pattern, OR
only partial response to usual treatment regimen
1 See INTERACT GI Symptoms Care Path 2 See INTERACT Shortness of Breath Care Path
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms E, F, G’s
Symptom or Sign
Immediate
Non-Immediate
Earache
Severe ear pain, bleeding or discharge from canal
Progressive or persistent ear pain
Edema
Abrupt onset unilateral leg edema, with tenderness
or redness
Rapidly progressive unilateral or bilateral edema
Eye injuries ( foreign bodies;
chemical burns; contusions)
Any eye injury
Any persistent redness of eyes not associated
with known injury or infection
Fainting
Sudden loss of consciousness
Fall
With any suspected serious injury (e.g. fracture)
any hip pain, or more than minor pain elsewhere
Fall with no or minor injury
Fever 1
New onset T > 100.5 F regardless of any other
symptoms ( unless under treatment already and
clinician already aware )
Gradual increase in temperature curve or recurrent
daily temperature spikes for more than two days
Fractures and
discolorations
Any suspected fracture or discoloration
Gait disturbances
Abrupt onset with slurred speech, or other new
focal neurological findings
1 See INTERACT Fever Care Path
Significant recent changes in gait without other
symptoms or findings
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms H, I’s
Symptom or Sign
Immediate
Non-Immediate
Head injuries
Any head injury with change in level of consciousness,
other mental status change, or any focal neurological
findings
Head injury not meeting Immediate
Notification criteria
Headache
Abrupt onset of progression of severe headache
with fever, change in mental status, or focal neurological abnormalities
Persistent nagging headache, unresponsive
to standard analgesics
Hearing loss
Abrupt onset or progression of hearing loss with fever
or focal neurological abnormalities
Abrupt onset of significant hearing loss without
other significant symptoms
Hematuria1
Gross hematuria with pain, fever or other signs
of bleeding at other sites
New onset blood-tinged urine without fever
or other signs of bleeding
Hypothermia
New onset T < 95, OR T more than two degrees
below usual with change in mental status or other
symptoms
New onset T < 95, OR T more than two degrees
below usual lower limits of normal, without change
in mental status or other symptoms
Incontinence
of urine or stool 1
New onset of incontinence with fever, neurological
abnormalities or other symptoms
Itching (pruritus)
Severe unremitting itching, OR occurring after
recent change in medications
1 See INTERACT UTI Care Path
Persistent mild to moderate itching unrelieved
by topical treatment or mild antihistamines
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms L, M, N’s
Symptom or Sign
Immediate
Laceration
Any laceration requiring sutures
Medication error
Causing any new symptoms OR involving
a cardiac, psychotropic, or other drug with
potential for significant toxic side effects
Medication side effects
Any abrupt symptoms or significant changes
in condition that might be associated with one
or more medications
Any minor symptoms or changes in status that
might be associated with one or more medications
Memory loss 1
Abrupt onset or progression of memory loss
with fever, change in level of consciousness,
or focal neurological abnormalities
Noticeable abrupt decline in memory or mental
status without other apparent symptoms
Musculoskeletal pain
Marked localized bruising, swelling, or pain over
joint or bone, with or without recent fall
Progressive or more frequent pain
Nausea and vomiting 2
Persistent or recurrent (two or more episodes within
12 hours) vomiting, with or without abdominal pain,
bleeding, distension, or fever
Intermittent recurrent nausea and vomiting
Nocturia
Nosebleed
Non-Immediate
Marked increase in nocturia from usual pattern
for >2 days
Acute nosebleed which persists despite simple
packing or pinching nostrils
1 See INTERACT Acute Mental Status Change Care Path 2 See INTERACT GI Symptoms Care Path
Recent minor nosebleed with more than minor
blood streaking
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms P, R’s
Symptom or Sign
Immediate
Non-Immediate
Pain
New severe pain, or marked increase in chronic pain
Increase in frequency or severity of pain
Personality change1
Abrupt significant change from usual, associated with
fever, or new onset of abnormal neurological signs
Recent minor but persistent change or fluctuation
in behavior, memory, or mood from usual
Pressure sore
New onset T > 100.5 F in someone with Grade 2 or
higher sore
New onset Grade 2 or higher pressure sore, OR
progression of pressure sore despite interventions
Puncture wounds
Deep or open wound, OR with more than minor
bleeding
Minor uncomplicated puncture wound
Rash
Rash in someone taking a new medication, OR
one known to cause allergic reaction
Recent onset of localized or diffuse pruritic rash, OR
any rash accompanied by other systematic symptoms
1 See INTERACT Change in Behavior Care Path
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms S’s
Symptom or Sign
Immediate
Non-Immediate
Seizure activity
Any new onset seizure activity, OR persistent seizure
in someone with known intermittent seizure activity
Self-limited seizure in past 24 hours in a resident
with known seizure activity who is already on an
anticonvulsant
Shortness of breath
(dyspnea)1
Abrupt onset of SOB with pain, fever, or respiratory
distress
Recently progressive or persistent minor SOB without
other symptoms, OR with progressive leg edema
Sleep disturbance
Difficulty sleeping
Sore throat
Accompanied by respiratory distress or inability to
swallow
Speech, abnormality 2
Abrupt change in speech, with or without other
focal neurological findings
Splinters /slivers
If unable to remove readily, with OR accompanied
by considerable pain or bleeding
If area appears to be infected, with erythema
or purulent drainage, OR if no tetanus shot within
past ten years
Suicide potential
Makes a suicidal gesture, OR discusses a detailed
plan for carrying out suicide
New onset of talking about wanting to die, but not
making any specific suicidal threats
Swallowing difficulty
With new onset or progressive choking, aspiration
Decreased intake from dysphagia, with potential
risk of dehydration malnutrition
1 See INTERACT Shortness of Breath Care Path 2 See INTERACT Acute Mental Status Change Care Path
With mild to moderate symptoms of upper respiratory
infection not responding to standard conservative
treatments
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Signs and Symptoms T, U, V’s
Symptom or Sign
Immediate
Non-Immediate
Toothache
Accompanied by fever, severe pain, redness,
or swelling in mouth, cheek, or jaw
Persistent or progressive discomfort not
responding to conservative measures
Urinary hesitancy
or retention
Abrupt decrease in urinary output, with lower
abdominal distension, discomfort over bladder,
or bladder volume > 400 cc
Progressive marked decrease in urinary output
over more than two days, OR new onset of post-void
residual > 300 cc
Vaginal bleeding
Bleeding with clots that saturate one pad
or more every two hours
Episode of bleeding that persist or that resolved
spontaneously
Vaginal discharge
or spotting
New or recurrent discharge or spotting
Vision, partial or
complete loss
Abrupt onset with pain, redness, or other symptoms
Recent significant change
Vomiting blood
(hematemesis)
New onset hematemesis with clots, OR accompanied
by rapid pulse or orthostatic BP drop
New or recurrent blood-streaked vomiting
without other significant symptoms
©2011 Florida Atlantic University, all rights reserved.
Signs and Symptoms W’s
Symptom or Sign
Immediate
Non-Immediate
Walking difficulty
Acute onset accompanied by other neurological signs
Recent onset not resolving spontaneously
Weakness, arm or leg
Abrupt onset of noticeable change in strength or use
Gradual recent onset not resolving spontaneously
Weakness, general
Abrupt onset of general weakness with fever or other
acute symptoms
Abrupt onset of general weakness without fever, change
in level of consciousness, or other acute symptoms
Weight, change in
Wounds
• New onset of anorexia with or without weight loss
• 5% or more within 30 days
• 10% or more within 6 months
• > 5 lbs in one week in resident with
- CHF
- chronic renal failure
- other volume overload state
Any wound that will not stop bleeding, OR that exposes
subcutaneous tissue
Apparently minor recent wound now developing
redness, swelling, or pain
©2011 Florida Atlantic University, all rights reserved.
Education on CPR
for Residents and Families
The Problem
Your Choice
Many health problems are so serious that they
cause your heart to stop beating. This is called
cardiac arrest. When this happens, you also stop
breathing.
CPR is a choice – it is not a treatment that everyone must have. Some people believe that when
their time comes or their heart or breathing
stops, nothing more should be done to keep
them alive. Other people want everything done
to keep them alive. Neither of these choices is
right or wrong. It is your choice.
The heart pumps blood to all organs in your
body to give them oxygen. When your heart
stops beating, your body and brain do not get
enough oxygen for you to live.
Treatment
There is only one treatment when your
heart stops beating. That treatment is cardiopulmonary resuscitation or CPR. CPR is done
to try to restart the heartbeat and breathing.
It is the only treatment that could save your
life when your heart stops beating.
CPR involves rapidly pushing on your chest,
and placement of a tube through the mouth
into the lungs to directly help you breathe.
Sometimes electric shocks are given using a
device called a defibrillator. Once started, CPR
is continued until your heart restarts or it is
clear beyond a doubt that your heart cannot
be restarted.
You should understand, however, that if you
choose not to have CPR, your choice will not
affect any other aspect of your care.
All of your other treatments and
care will continue.
The only thing that will
change is that if you
are found without
a pulse or heartbeat
(in cardiac arrest)
CPR will not be done.
CPR can be started in the nursing home, but
as soon as possible, you will be transferred to
the hospital, often an intensive
care unit, for additional treatment and monitoring.
(continued on reverse)
©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.
Education on CPR
for Residents and Families (cont’d)
Making the Decision: CPR or DNR
Many people make a decision in advance about
whether or not they want CPR. You can choose
between having CPR and asking for a ‘Do Not
Resuscitate (DNR)’ order. If you choose the DNR
order, CPR will not be done if your heart stops
beating. You are unlikely to be able to make this
decision for yourself at the time your heart stops
beating. Making the decision in advance will
help make sure that your wishes are carried out.
The decision whether or not to have CPR can be
a difficult one. You may want to discuss it with
your family, doctor, nurse, social worker, or a
religious leader.
Understanding the benefits
and risks of CPR is important
when you make your
decision. The chart below
explains the benefits and
risks of CPR.
Benefits of CPR
Risks of CPR
If your heart stops beating, CPR is the only
treatment that could save your life. However,
you should also know that the rate of surviving
CPR is low.
• On average less than 1 in 10 people who
receive CPR outside of a hospital survive.
• The chances of surviving CPR are even lower
in people of advanced age, and in people with
serious medical problems such as advanced
forms of cancer and diseases of the heart,
kidneys, and liver.
Although in some cases CPR can save your life,
CPR itself can cause bodily harm. For example:
• Many people, especially older people with thin
bones, suffer broken ribs as a result of CPR.
• There is a small chance that if you survive CPR,
you can have severe brain damage or be in a coma
for some time or even the rest of your life
Help in Making Your Decision
have information available in print and on
their websites that may be helpful to you.
There are many resources available to you
in making this decision. Organizations
such as the American Association
for Retired Persons, the Coalition
for Compassionate Care, the
Conversation Project, Closure,
and Caring Connections of the
National Hospice and Palliative Care
Organization, as well as many others
In addition, most states have standard forms for documenting your
decisions in advance (‘Advance
Directives’), and many are recommending completing an order
form in advance, such as Physicians
Orders for Life Sustaining Treatment
(‘POLST’) or other similar forms.
©2011 Florida Atlantic University, all rights reserved.