Building Your Resident Safety Net
Author – Cyndi Siders, RN, MSN, CPHRM, DFASHRM, CPPS, Executive Consultant
Mrs. Sally Smith, an active 83-year-old, had a mild stroke in January. Her right side was affected as well as her speech. Sally has been in rehab for the past two weeks, and while she is improving, she is still very weak. Sally tells you on admission that she is excited about the possibility of returning home as soon as possible. Her son and daughter have expressed to you, in private, that they are concerned about Sally’s ability to continue to live alone.
Sally is being admitted today for continued rehab at your facility. Her expectations are high that she will be home to plant her spring flower beds. Her dream of returning home may become a possibility IF:
• IF her fall risk is managed through appropriate interventions
• IF it is recognized on admission/medication reconciliation, that some of her home meds were held in the hospital and not reordered on discharge, including her anti-hypertensive medication
• IF the reddened area on the side of her foot is recognized early and treated with appropriate skin integrity measures
• IF it is recognized that Sally’s appetite is significantly diminished and that she has a bit of a hard time taking fluids
IF, many IFs are recognized and managed with appropriate interventions and IF her clinical condition does not change and IF she is able to progress in therapy, then MAYBE she might be able to move home to plant her spring flowers.1
Risk Management Considerations:
A resident-centered care delivery model that supports person-centered care needs, early identification and response to clinical risks, and daily safety observations are critical elements of a Resident Safety Net.
✓ Communication – Communicate clear and concise information during hand-offs, bedside reporting, and provider communication. Ask the question – What does the next person need to know to continue to care for this resident?
The information will be different depending on the purpose of the hand-off communication. For example, physical therapy would need to know about any changes in fall risk, changes in skin integrity, changes in medications that may impact balance and movement, and changes in clinical condition that may impact physical and cognitive response. The emergency department would need specifics about current condition (e.g., vital signs, cognition), recent changes in clinical condition, new medications and medication response, pertinent resident history (e.g., diabetic), risk factors for injury (e.g., fall risk, skin integrity) and interventions that are in place to minimize risk.
✓ Documentation – Document assessment, monitoring, interventions, and resident response to interventions, care, and treatment. Note clinically pertinent observations and findings, resident and family instructions and education, provider notification of changes in condition, incidents (e.g., fall), adverse events (e.g., medication reaction), and resident non-compliance. Document at the point-of-care delivery whenever possible.
✓ Resident Engagement – Engage the resident in care planning, care decisions (as they are able), and care choices. Support physical, emotional, cognitive, and spiritual needs. What is on their bucket list? Things yet to be done… Support these opportunities for personal growth and fulfilment.
✓ Family Engagement – Families can be your strongest advocate, or they can be your strongest adversary. Families are often the ones that call the State or call plaintiff attorneys when they have complaints or an adverse event occurs. Invite residents and family members to share their concerns as they occur. Update family members regularly with changes in condition and when adverse events occur (even minor events). Regular communication helps to establish trust and confidence in the care that is being provided. Engage families in planning all activities that involve quality of life, quality of care, and safety for their family members.
✓ Customer Service – Residents and families have choices, and there are often many organizations competing for the same opportunity to serve a growing number of seniors. In addition to looking for a clean and comfortable environment, quality and affordable services,
✓ Team Member Support – A team of healthcare professionals with Situational Awareness (“Situation awareness is the state of knowing the conditions that affect one’s work. This awareness is achieved by constantly monitoring the ever-changing situation”2) is able to adjust work processes and flow to support one another. Situation awareness is the extent to which team members are aware of the following: Status of the Resident, Status of the Team, Status of the Environment, and Status of the Plan.
✓ Honoring Resident Rights – All nursing homes are required “to provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care that… is initially prepared, with participation, to the extent practicable, of the resident, the resident’s family, or legal representative.” This means a resident should not decline in health or well-being as a result of the way a nursing facility provides care.”3 Know and Understand Resident Rights, Be a Resident Advocate.
✓ Emergency Management – Preparedness can mean the difference between life and death for residents, family members, and staff in an emergency situation. Be Informed about facility emergency procedures, Be Proactive in identifying and reporting emergency conditions, Be Clear when providing communication about emergencies (e.g., 911), and Be Responsive and Timely in following facility policies and procedures for emergency response.
✓ Abuse Prevention – “Each year hundreds of thousands of older persons are abused, neglected, and exploited.”4 Elders can be abused by family members, caretakers, visitors, other residents and healthcare providers. The Centers for Medicare and Medicaid Services defines abuse as “…the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.” “Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.”5 Be Knowledgeable, Be Observant, Provide Medical Care and Treatment for Injured Residents, Provide Safety (as needed), and Report Immediately.
✓ Fall Reduction Interventions – Each resident has intrinsic (e.g., medications, health conditions, cognition) and extrinsic risk factors (e.g., mobility devices, condition of glasses) that potentially increase their risk for a fall injury. Completing a fall risk assessment on admission, change in condition, change in medications, readmission, after a return from an emergency room visit, or change in mobility is an essential component for minimizing the risk of falling for residents. Additionally, implementing the appropriate safety interventions and monitoring their effectiveness is critical for sustained resident safety.
✓ Skin Integrity – During the aging process physical changes occur, such as loss of skin elasticity, thinning of the skin, and loss of normal sensation. All of these changes may contribute to skin concerns, including bruising, skin tears, or other more serious wounds like pressure ulcers.6 To minimize the risk of skin integrity issues, complete a formal skin assessment on admission, readmission, change in condition, significant change in medications, and for residents at least quarterly.
✓ Elopement Prevention – We have all read the stories of the senior that walked away from their senior living community and was found frozen in the snow or the senior that drowned in a pond (e.g., “A 77-year-old man who apparently walked out of a senior living facility Sunday night in Oak Park Heights was found dead outside early Monday morning. Thomas LeCloux, a retired principal of Oak-Land Junior High School in Lake Elmo, is believed to have fallen outside and died of exposure to frigid weather.” 7 [December 2016]; “The Charleston County coroner says it appears a 90-year-old woman found dead in a pond after disappearing from her nursing home was killed by an alligator.” 8 [July 2016]). Elopement and wandering assessments on admission and change in condition, interventions, and monitoring are essentials elements of proactive management of this resident risk.
✓ Monitoring Daily Safety Needs – Vigilance at the Bedside Saves Lives!!
✓ Infection Prevention – In the elderly, infections may present with symptoms that include loss of appetite, dehydration, weakness, and confusion. Common infections in the elderly include, but are not limited to: urinary tract infections; skin infections (e.g., herpes zoster – shingles, bacterial or fungal foot infections, cellulitis, and drug-resistant infections like MRSA); bacterial pneumonia; influenza; and gastrointestinal infections.9 Proactive measures including handwashing, personal protective equipment, appropriate cleaning protocols, visitor restrictions during periods of infection risk, and resident and family education are important elements of minimizing infection risk.
✓ Resident/Family Education – Resident-centered care includes providing information, education and resources to support informed decision-making and in some cases informed-refusal.
✓ Five + Rights of Medication Administration – Ensure that medications are being provided following the “Five+ Rights” of medication administration (e.g., right drug, right patient/resident, right dosage, right route, right time and frequency, right documentation, right reason, right response, and right education and information). Consider a double-check process, after key medication administration times, to ensure that all medications have been administered.
✓ Confidentiality – Residents have the Right to have their personal, financial, business and medical information protected (with the exception of reporting that is required by state and federal law, provider communication, and for insurance and billing purposes). Know and understand HIPAA privacy and security requirements.
✓ Near Miss Reporting – Near misses are opportunities to identify potential problems before they become serious problems. Each near miss should be looked at as having the potential to be the next serious event at the facility. Report near misses following facility reporting procedures.
1. Story idea adapted from Berwick, D, Luo, E. Engineering the System of Healthcare Delivery. Edited by W.B. Rouse and D.A. Cortese. IOS Press, 2010. Chapter 2. Seeking Care as a System.
2. Agency for Healthcare Research and Quality. TeamSTEPPS® Fundamentals Course: Module 5. Situation Monitoring. https://www.ahrq.gov/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL11
3. National Long-Term Care Ombudsman Resource Center. Residents’ Rights. http://ltcombudsman.org/issues/residents-rights#what
4. U.S. Department of Health and Human Services. Administration for Community Living (ACL). Administration on Aging (AoA), What is Elder Abuse? https://aoa.acl.gov/AoA_Programs/Elder_Rights/EA_Prevention/whatIsEA.aspx
5. Federal Register / Vol. 81, No. 192 / Tuesday, October 4, 2016 / Rules and Regulations
6. GuideOne Insurance Company. Admission letter.
7. Twin Cities Pioneer Press. Missing Oak Park Heights man, 77, found dead of apparent exposure. http://www.twincities.com/2016/12/19/elderly-oak-park-heights-man-found-dead-of-apparent-exposure/
8. CBS News. Woman, 90, found dead in a pond after likely alligator attack. [July 29, 2016]. http://www.cbsnews.com/news/woman-90-found-dead-in-pond-after-likely-alligator-attack/
9. A Place for Mom. Senior Living Blog. The 5 Most Common Infections in the Elderly. http://www.aplaceformom.com/blog/2013-10-22-common-elderly-infections/
This blog, which does not reflect any official policy or opinion for Vaaler Insurance, Inc. or Siders Healthcare Consulting, LLC, is provided for informational purposes only. It is not intended to provide legal or medical advice, nor is it intended to be an exhaustive list of all risks that need to be addressed for a healthcare organization. While every effort is made to provide accurate information, changes may occur and inaccuracies happen despite best efforts. This information is not a substitute for individual consultations with professionals in these areas and should not be relied on as such. Please work with your legal counsel and business advisor(s) for a plan that is specific to your organization. © 2017 Vaaler Insurance, Inc.