Long-Term Care Survey Alert

Published on Mon Jan 09, 2006 PDF

Prevent communication slip-ups at these 2 common transitions in care.

Managing how well you "hand off" a resident to another caregiver has become the latest buzz in patient safety circles -- one that you can bet will be appearing on surveyors' radar screen.

Know the definition: A "hand-off" communication "is a contemporaneous, interactive process" where caregivers pass along resident-specific information for the purpose of ensuring the continuity and safety of care, relays Marianna Grachek, RN, MSN. Grachek is executive director of Long Term Care and Assisted Living Accreditation for the Joint Commission on Accreditation of Healthcare Organizations.

New in 2006: JCAHO has added a new requirement mandating accredited long-term care facilities to "implement a standardized approach to 'hand off' communications, including the opportunity to ask and respond to questions." The requirement meets patient safety goal No. 2: "Improve the effectiveness of communication among caregivers".

A Good Model to Follow

Even if your facility isn't accredited, take a hard look at your own protocols for ensuring caregivers don't let vital information about a resident fall through the cracks when they transfer care duties to another person.

Example: If a nursing assistant fails to communicate to the person covering for her at mealtime that a particular resident needs a two-person assist, the resident or staff member will be at risk for injury, says Grachek.

Solutions: Post an abbreviated care plan for each resident in an easily accessible place, including the back of the person's closet, suggests Celia Strow, RN, MPS, CNHA, FACHCA. Strow is a former nursing home administrator and current CEO of MyZiva.com, a nursing home management resource. "The simplified version should include the essential care plan interventions, such as NPO status, turning and positioning schedule, one- or two-person assist, DNR orders, etc.," Strow says.

In addition, "some facilities use a checklist system where the CNAs check off what needs to be done in their absence for each resident, including toileting, rechecking vital signs, etc.," says Strow.

Lest the person going on meal break rebel against completing paperwork, the checklist should be a brief one with boxes allowing the CNAs or nurses to mark key elements of care or other information for the person covering for them. The caregiver leaving the unit should also give a brief verbal report to the person taking over for her, Strow says.

Another idea: Use color-coded ID bracelets to identify residents who have DNR orders, diabetes, allergies, fall precautions or those receiving thickened liquids, suggests Strow. "Facilities must check to see if their identification practices" meet HIPAA privacy requirements, she adds.

Tackle Shift Changes

Licensed nurses also have to receive and pass along critical information from CNAs from one shift to the next.

The problem: CNAs typically work 7.5 hours per shift, so if they do their own documentation, they often leave before the nurse has an opportunity to ask questions or validate their data, says Joan Redden, RN. Redden is vice president of clinical risk management for Skilled Healthcare LLC, a nursing home management company in Foothill Ranch, CA.

Solution: CNAs can maintain documentation of their care and observations on work sheets (ADLs, turning and positioning, bowel and bladder records) and then share the information verbally with the nurse at shift change, advises Redden. That approach gives the nurse an opportunity to ask the nursing assistant to fill in the blanks and confirm the resident's ADL status, elimination, fluid intake, skin care, etc., advises Redden.

CNAs know residents best: The nurse can also ask the CNAs who care for the same residents regularly if they observed any subtle changes in the resident's behavior, appetite, ADL functioning, etc. -- and how the resident compared to the previous time the person took care of the person, suggests Redden. Asking that question can pay off in spades. One CNA reported at shift change that a resident with a ventricular shunt known for winning dominoes had lost every game that day, Redden reports. "The CNA's report alerted the nursing and medical staff that the man had a problem with his shunt, which allowed the interdisciplinary team to intervene early."

Survey tip: Giving CNAs a regular opportunity to provide input about the resident -- and documenting and acting on the information -- can head off a CMS 2567 where surveyors quote a nursing assistant saying she informed the nurse about a resident's problems weeks earlier, Redden says.