Risk Management and Quality Improvement in LTC

1. Risk Management and Quality Improvement in LTC Karl E. Steinberg, MD, CMD Associate Medical Director, Scripps Coastal Medical Center, Oceanside President, California Association of Long Term Care Medicine (CALTCM) Medical Director, Las Villas de Carlsbad HC, Village Square Nursing Center, Hospice by the Sea Editor-in-Chief, Caring for the Ages

2. Objectives Consider When to Call Doctor & What to Say Review Notification Requirements Importance of Informed Consent & Refusal Discuss Common Documentation Problems/Errors Realistic Goals for Care Plans Explore Issues With Unrealistic Residents & Families

3. Objectives • Associated Documentation Issues & Risk Management Strategies • Vital Signs, O2Sats • Assessments • I/Os, Hydration, Nutrition • Turning & Repositioning, Pressure Ulcers • UTI vs. Asymptomatic Bacteriuria • Issues in Diabetes, Anticoagulants, Depression • Recognize Current Negative Public Opinion of our Industry & Strive to Improve It! • Compassion, Empathy, Human Touch Go a Long Way

4. Contacting the Physician • True Emergencies: Obviously, Use Most Immediate Method (Pager, etc.) • May Need to Take Action without Orders • Significant but not truly Emergent symptoms: Consider Personal Preferences of MD/DO, but do not compromise patient safety • Moderate Symptoms, Need System to Ensure Follow-Up is Obtained! (& Documented) • Minor Symptoms (Skin Tears, Weight Fluctuations, Non-Injury Falls) • Consider Fax with Printed Confirmation Sheet

5. Methods of Communication • Direct/Immediate (In Person, 2-Way) • By Telephone (Direct Conversation, 2-Way) • By Voice Mail Message (Indirect/One-Way) • Via Fax (Indirect/Passive, One-Way) • Log Book or Communication Book (One-Way) • E-mail (One-Way) • Via EHR System • Via Alpha Pager or Text Message (One-Way) Different Situations Require Different Documentation

6. Notification is Mandatory!42 CFR §483.10 (a)(11) • Notification of changes. • A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is— • (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; • (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); • (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or • (D) A decision to transfer or discharge the resident from the facility as specified in §483.12(a).

7. Notification is Mandatory!42 CFR §483.10 (a)(11) • Notification of changes. • When in Doubt, Notify! • Failure to Timely (“Immediately”) Notify Physician & Family Member May Result in Deficiencies/Citations • Can also Result in Successful Lawsuits • Important to Document Notification • If Unsuccessful, Keep Trying • And Keep Documenting! • Use Nursing Judgment • Call for Backup if Needed • DON, Medical Director • Administrator/Executive Director

8. Other Times to Initiate Contact • Abnormal Vital Signs (What Does This Mean?) • Skin Breakdown • Poor Dietary or Fluid Intake • Weight Loss • Falls/Near-Falls • Abnormal Laboratory Studies • ***Family Concerns *** • Usually OK to let Family Know How to Contact Doc • Usually NOT OK to Page Doc from Nurses’ Station for Family & Hand Phone Over! (Ambush!)

9. Other Times to Initiate Contact • Resident Symptoms (Pain, Cough, Dyspnea, Bowel Irregularities, Dysuria, Confusion, etc.) • When an Order is Not Carried Out as Directed • Labs Not Drawn for any Reason • Medication Not Administered or Delivered (Timely) • Can Solicit a Substitute from E-Kit if Appropriate (esp. for Pain or when Serious Infection is Suspected) • Refusals of Medication or Treatment • Refusals of Turning & Repositioning or Use of Splints, Adductor Pillows, Heel Protectors, etc. • Unexpected Delays in Appointments for Test/Consult

10. Sophie & Tessa

11. Established Principles for Effective Communication • Except in Emergencies, Take Time to Prepare! • Do An Appropriate Assessment Before Calling • Have All Information Ready for Provider • Consider Calling Responsible Party First • Assess and Mention All Relevant Diagnoses • Know the Preferred Intensity of Treatment! • It’s OK to Have an Agenda, but Be Flexible • Worth Having it Written Down Beforehand • Consider SBAR or Similar Pre-Printed Forms

12. Specific Strategies for Effective Communication/Notification • Have All Information Ready for Physician • Chief Complaint & Associated History • Vital Signs, Full Set, Recent! • Actually Do a Respiratory Rate • Include Orthostatics if Appropriate • Oxygen Saturation • Results of Focused Physical Assessment • e.g., Lung Sounds, Abdominal Exam (Bowel Sounds, Tenderness, Distention), Cardiac Rhythm/Sounds • Check for Impaction, Check for Bladder Distention • Assess Mental Status in Comparison to Baseline • Actually Assess Orientation—Residents Can Fool You! • Delirium Grossly Underdiagnosed & Carries Poor Prognosis

13. Specific Strategies for Effective Communication/Notification • Have Medication List Handy • Know if Resident is on Coumadin (Antibiotic Interactions) • Know if Resident is or has been on Antibiotics recently • (Increased Risk of C. diff., Yeast, Drug Reaction, etc.) • Have MARs with recent Blood Glucose values if applicable, and Current Sliding Scale Coverage • Know when last BM & Void Occurred, Meal Intake • Know Hx of Previous Impaction, Retention, Infections • Consider the Use of a Standardized Form • Can Create Facility-Specific, Symptom-Specific Forms • Get Medical Director to Provide Input!

14. Specific Strategies for Effective Communication/Notification • Consult with Other Personnel if Available • CNA Usually Knows Resident Best! Talk to Them! • Therapy Staff • Social Services or Case Manager: Is Discharge Looming? • Talk to Resident and/or Family (if Non-Emergent) • Know Code Status and Preferred Intensity of Treatment • Consider Diagnostic & Therapeutic Measures In-House • Obtaining Labs/X-Rays • IV Hydration • IV Antibiotics • Respiratory Therapy (Nebulizers, Incentive Spirometry, Steroids, O2) • More Frequent Monitoring: Vitals, Sats, Mental Status, etc. • Define Callback Parameters

15. Specific Strategies for Effective Communication/Notification • Have Most Recent and Older Labs/XRs at Hand • Important to Provide Baseline & Comparative Values • Have a Summary of Your Impressions & Concerns • Have an Idea of What Your Wish List for the Situation Is—Offer it if Appropriate • Must Consider Individual Practice/Personality Styles of Providers: In Some Instances, Tread Lightly • Also Consider Individual Factors of Resident/Family • Be an Advocate for Your Residents • Have a Policy Mandating Read-Back of All New Orders, and Enforce It! (Safety First!)

16. Specific Strategies for Effective Communication/Notification • If Nurse is Uncomfortable with MD/DO/NP/PA Response—Call an Authority within the Facility to Discuss (DON, Admin., Medical Director, etc.) • Need to Practice in Accordance with Your Principles • If Something Doesn’t Feel Right, It May Not Be Right • But Also Need to Consider Your Own Limitations • In Some Cases, Turn Care Over to Another Nurse • Need to Consider Your Own Professional License • Need to Consider Facility/Corporate P&P • Sometimes Involves Taking Alternative Action • If You Have Corporate Backup, Use It! (Consultant, Regional Nursing or Risk Management Professional, etc.)

17. P O LST

18. Growth Areas for Quality • Hold Parameters on Medications • An Excellent Idea in Principle, Should Improve Safety • Needs to Be Consistently Implemented • May Require More Frequent Monitoring • Generally Physician-Driven • Most Commonly Used with Antihypertensives, Digoxin • May Hold Antihypertensive for SBP<95-120 • May Hold Digoxin or Beta-Blocker for AP<50-60 • Also Consider What Holding Medication May Do • Should Consider Holding Opioids for Excess Sedation or RR<8-10 • Nebulizers, Sliding Scale Insulin are Grossly Overutilized. Rarely Truly Necessary.

19. Growth Areas for Quality • Dehydration a Common Problem & Cause of Change in Condition • Can Present as Lethargy, Abnormal VS (↑ HR,↓BP) • Vicious Cycle as Intake Diminishes Further • CNAs Often the First to Notice Subtle MS Changes, ↓ Intake • CNAs Also First Line of Defense in Prevention & Tx • Empower CNAs—Encourage Communication, Listen To & Appreciate Their Input! • Snack/Hydration Carts A Good Idea • Sometimes, Relative “Dehydration” is Desirable (Diuretics, CHF) • Clinical Signs of Dehydration Somewhat Unreliable Until It is Advanced, But their Presence or Absence Should Be Documented • Skin Turgor (Consider Forehead) • Mucous Membranes, Sunken Eyes, Dry Axilla • Lab Work More Definitive, (Not Just BUN & Creatinine: Sodium, Urine Specific Gravity, sometimes Urine Sodium)

20. Growth Areas for Quality • Dehydration Is Sometimes Unavoidable: Document Discussion w/Responsible Party When This Occurs • Educate Family About Options • When CHF is Present, Some Degree of Iatrogenic Dehydration Is Desirable • Dehydration Has a Bad Reputation as Cause of Death • Largely Undeserved Reputation: Educate!! • Enlist MD/DO/NP/PA Assistance • Consider IV Hydration in Facility, or Hypodermoclysis (Subcutaneous Infusion) …Rather Than Automatic Shipping to ER • Nutrition: ‘Therapeutic’ Diets Not Helpful • Usually Do More Harm than Good • Families/Residents May Need Education

21. Growth Areas for Quality • Dehydration Is Sometimes Unavoidable: Document Discussion w/Responsible Party When This Occurs • Educate Family About Options • When CHF is Present, Some Degree of Iatrogenic Dehydration Is Desirable • Dehydration Has a Bad Reputation as Cause of Death • Largely Undeserved Reputation: Educate!! • Enlist MD/DO/NP/PA Assistance • Consider IV Hydration or Hypodermoclysis (Subcutaneous Infusion) Rather Than Automatic Shipping to ER • Nutrition: ‘Therapeutic’ Diets Not Helpful

22. Growth Areas for Quality • Falls: Complete post-fall analysis before calling unless severe injury suspected or transfer required • Check vitals including orthostatics • Full Body Check • If unwitnessed, careful consideration of possible head injury • Fingerstick Blood Sugar if diabetic • Current Fall Prevention Measures • History of Previous Falls • Anticipate what an IDT would do • Help Doc Make Appropriate Choices (Add Tab Alarm, Low Bed, Mats, Lap Buddy, etc.) • If your facility is “Restraint-Free,” make sure Resident/Family aware, and that other facilities may not have that policy (Medicolegal and Liability Issues)

23. Documentation Quality Issues • Important to Individualize Charting (esp. Narrative) • Care Plans Are Often Highly Generic, Goals Unrealistic • Narrative Notes Should Include Some Physical Assessment! • “Call Light Within Reach”—A (Usually) Meaningless Notation • “Alert & Verbally Responsive”: Not Enough! Tell More! • “URI”—Usually Not Really Upper Respiratory Tract • Alert Charting Should Actually Be On the Alert for Something! • Turning & Repositioning: Protocols Should Be Used and Documented. In High Risk Residents, Maybe Every Turn! • Education & Discussion of Risks, Benefits, Alternatives Should Always Be Documented

24. Basic Risk Management • Accept That SNFs Are Viewed Negatively by Public • Make an Effort to Humanize Care & Caregivers • Clarify HIPAA Issues Early On, Obtain Permission to Discuss Resident w/All Appropriate Parties • If You Don’t, There Will Be Bad Blood! • Don’t Be a HIPAA Zealot! • Consider Risks vs. Benefits of Discussing • Help Create Realistic Expectations • Some Complications Unavoidable • Train All Staff to Be Compassionate, Empathetic & Respectful

25. Risk Management Strategies • Foster an Attitude of Compassion • Provide the kind of care you’d want your family to get • Always greet residents/visitors and ask if they need help • Respond promptly to phone calls and other concerns • Treat everyone in the building with respect • Have a Greeter/Receptionist (a Friendly One!) • Convene Ethics Committees when appropriate • Use Medical Director in complex or sticky situations • A Good Ombudsman Can Be a Great Asset • Avoid Value Judgment in Documentation • Be complete in Documentation whenever possible • Avoid “Charting Parties” and “Shadow Charting” • Ensure Adequate Staffing, but Avoid Registry • Good Evidence Exists that Consistency/Continuity of Staff with Individual Residents Results in Improved Outcomes

26. Risk Management Strategies • You Know Who the Problem Families Are! • Be Proactive With These People! • Do Extra Charting, Extra Vitals, Extra Calls to Doc if needed • Document Conversations with Resident/Family • Document Conversations with Attending Physician • Involve Ombudsman When Appropriate • Try to Work Collaboratively, Do Not Bad-Mouth Anyone • Be Caring! Or Act Like It! • Have Extra Team Meetings to Address Specific Concerns • Have People Sign Waivers When Doing Something that’s Against Medical Advice • Even Though They Will Claim You Never Explained It, Can Be Helpful in a Lawsuit • Get Attending MD/DO and/or Medical Director to Assist with Documentation on Problem Residents

27. Pressure Ulcers are a Huge Source of Pain, Medical Expenses & Liability • Also Not All Avoidable • Some Good Evidence that ‘Skin Failure’ is Part of Dying Process, Interventions May Not Work • Always Care-Plan & Manage Pain! • Education of Resident/Family is Useful • Create Realistic Expectations • Documentation & Care Planning Critical (T&R!!) • Use Specialty Mattresses, Wound Consults Early • Saving One Lawsuit Is Worth Expense • Make Sure Physician Kept In The Loop Growth Areas for Quality

28. Participate as a Facility • CAHF: QCHF & Other Offerings • California Association of Long Term Care Medicine (CALTCM) www.caltcm.org • Education, Advocacy, Cutting-Edge Medical Updates, Networking, Medical Directorship • Annual Meeting July 10-12 in LA at Omni. Save the Date! • POLST Implementation Pre-Conference July 10 • Advancing Excellence Program • www.nhqualitycampaign.org • Multiple Goals/Parameters to Improve Quality • American Medical Directors Assoc. (AMDA) • National Organization for Medical Directors • Clinical Practice Guidelines, Toolkits

29. Take-Home Messages • Transfers & Other Transitions in Care Settings are a Major Source of Errors …and a Great Opportunity for Growth! • Documentation is Critical: Accurate, Complete, Individualized, Relevant, Resident-Centered • Team Approach is Optimal: Consider and Respect All Opinions, Especially CNAs • Create (& Document) Realistic Expectations • When Not Possible, Document Unrealistic Ones

30. Take-Home Messages • Engage Medical Director, Ensure Interest & Participation in Education, Organizations • Join CALTCM as a Facility: www.caltcm.org • Medical Director Should Consider CMD Certification • If Medical Director Not Active, Change That! • Get Outside Help When Appropriate • Devise Action Plans for Building-Specific Issues • Falls, Pressure Ulcers, Dehydration, Bacteriuria/UTI, Identification of Delirium are Good Places to Start • Policies & Procedures Should Be Current, Evidence-Based, and Actually Followed! • Consider Using AMDA’s Clinical Practice Guidelines and Tool Kits www.amda.com

31. Take-Home Messages • Maintain Attitude of Empathy and Humanity • Consider Palliative Care Early When Appropriate • Our Work Is Valuable, Important, Compassionate and Loving • Culture Change Is Upon Us: Let’s Work to Improve Public Perception of Our Industry! • Keep Striving to Improve Quality and Reward Innovation • Get Support and Input from Medical Director