Short Term Health Monitoring & Change of Condition

1. Short Term Health Monitoring&Change of Condition The Key to Communication

2. Short Term Health Monitoring & Change of Condition form • Purpose: • Residence Nurse staff instruction • Stand up shift report between staff • Communication report for weekly to Quality • Assurance Director for All Reportable Events by Thursday.

3. Short Term Health Monitoring & Change of Condition Administrator, Nurse & Staff Instruction • Form allows for simple communication between All parties caring for Residents and allows for us to Create a Target list of High Risk Residents • Instructs Caregivers on specific acute conditions/changes of condition that need to be monitored & documented in the Residence Progress Notes • Change of Condition: a change in mental or physical status that results in a need for us to provide extra or different services. A change in resident’s ability to participate in 2 or more activities of daily living, such as eating, bathing or dressing.

4. Short Term Health Monitoring & Change of Condition Stand-up shift report between staff • Creation of a standard tool for communicating between shifts. • Residence nurse, staff and Administrator to update Short Term Health Monitoring/Change of Condition form a review with staff during staff meetings. • Caregivers are to communicate/update oncoming staff to status of identified residents. GOAL: Enhance Continuity of Care & Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay

5. Short Term Health Monitoring & Change of Condition Residence Nurse/Administrator Communication Report GOALS: • To enhance the residents quality of care • Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay • To insure continuity of care • To insure appropriate updates to Negotiated Service Plans

6. Short Term Health Monitoring & Change of Condition Weekly Regional Nurse Consultant Report • Consolidate forms used by residence nurses and meet reporting requirements • Completion of report by residence nurses to include incidents identified on Decision Tree for Event Reporting • Assist RNCs with case management of complex resident issues

7. How to complete the Short Term Health Monitoring & Change of Condition • Once a resident is identified as requiring short term monitoring, the Change of Condition form should be updated • Begin with the first two columns: add the date and resident name • In the 3rd column, the residence Admin &/or nurse should specify the specific condition they wish the staff to monitor & report on

8. How to complete the Short Term Health Monitoring & Change of Condition • In the 4th column the residence nurse should indicate the current status of the resident: • Did the resident remain in the house? • Was the resident admitted to the hospital? • Is the resident receiving services from home health, hospice out patient rehab services?

9. How to complete the Short Term Health Monitoring & Change of Condition • The residence Admin &/or nurse should list all interventions, orders or treatments initiated due to the change of condition • The residence nurse should indicate who is providing the services: home health PT, OT, Nursing, Residence Nurse, Caregivers

10. How to complete the Short Term Health Monitoring & Change of Condition • The residence Admin & nurse should provide staff with detailed instructions for monitoring, treatments/interventions & documenting

11. How to complete the Short Term Health Monitoring & Change of Condition • The residence Admin & nurse should indicate the residents expected outcome. • Examples: skin tears/wounds-indicate the anticipated healing date, rehab services- indicate expected goal/outcome from services • The Residence Admin & nurseshould also indicate the anticipated return date if the resident is hospitalized or in a rehab facility

12. How to complete the Short Term Health Monitoring & Change of Condition • The residence Admin & nurse should indicate whether they are reviewing or discontinuing the monitoring of the resident and supply date • The Residence Admin & Nurse should verify that an incident report was completed by a “Yes or No” response