Long-Term Care Survey Alert
Go By The Book--Capture, Home In On Critical Resident Care Information
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Head off charges of failure to respond to residents' needs in time.
The last thing you want to lose during shift change is a critical bit of resident-care information scribbled on a piece of paper or sticky note.
Solution: Some facilities use a 24-hour report book to share information with the next shift, suggests Celia Strow, RN, MPS, CNHA, FACHCA, a former nursing home administrator and current CEO of MyZiva.com, a nursing home management resource. The information documented in the 24-hour report book might include the following:
• Changes in residents' conditions, including an increase in ADL assistance or new or escalating behavior symptoms
• Fever and other unstable vital signs
• Abnormal labs
• Scheduled labs, procedures, etc. on the coming shift or next day
• Doctors' appointments
Tip: Twenty-four hour report books could include a place for CNAs to document their observations, including a perception that the resident "just wasn't himself today," suggests Cheryl Field, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA. "That's the language CNAs use," says Field. In such cases, licensed nursing personnel should ask more questions and do an assessment of what's different about that resident, she says.
Field also recommends using the 24-hour report as an internal quality assurance tool.
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