MDS Alert
Nursing Facility Highlights Must-Dos for Shift Report
PDF
Spelling out the process helps staff know what to report. MaineGeneral Rehabilitation & Nursing Care Guides for Effective Shift Handoff Communication Skin Risk: It is unimportant to state, "resident with skin risk." It is important to give the focused report. "This resident is at risk for skin breakdown. She was repositioned in her chair at 2:20. She has her heel hover boots on. No red areas noted. Fall Risk: It is unimportant to state, "resident with fall risk." It is important to give another focused report. "This resident is at risk for falls. She was very anxious in her chair today, she walked from the day room to the bathroom, had a large BM and is now sleeping in her chair. She may get anxious again on your shift. Try taking her for a walk." Include if pertinent whether the resident is being compliant with her safety plan. Discuss the plan. Discuss further options for keeping the resident safe. Pain: Report if the resident had pain during your shift. Discuss the plan with the nurse, so that everyone is aware of the resident's pain plan. Many times, a resident has scheduled medications AND PRN medications. When was the last time the resident was medicated? When can the resident be medicated again? Weight: Is the resident at risk for weight loss? If you report the weight, report whether this is a CHANGE from the resident's previous weight. Did the resident's appetite change recently? Are they tolerating their texture? Are they accepting liquids? Are they accepting of snacks, like custard or ice cream? Do they already have a 2 cal or an Ensure care-planned, are they accepting it? Behavior: Is the behavior at baseline? Is the behavior combative in nature? What is the plan for the behavior? Is it working? Was a medication changed recently? Remember mood and behavior medications can take 2-3 weeks for optimum effectiveness. Acute Concerns: Is the resident declining? What does the POLST [Physician Orders for Life-Sustaining Treatment] indicate, or what is the plan for the family? The nurse may want to monitor for a shift to see if the resident returns to their baseline, depending on vital signs and family plan. Is the resident on an ABX? Should we be encouraging fluids? Has there been a change in the resident's risk factors? Who is going to get follow up vital signs if appropriate? Restorative Plans: If a resident is unable to participate in a restorative plan we need to be talking about it. Maybe the next shift will have more success. If the resident is unable to participate for a few days we need to consider a decline, if PT/OT isappropriate. Skilled Care: If a resident is receiving skilled care, it should be mentioned in report. Why are they receiving skilled care? What is going on? Is it improving? Are we monitoring vital signs? Who is going to get them for the nurse during the next shift? When? WINS: Share wins! Did the resident have a really good time at the music program today? Did the resident enjoy a specific food at lunch? Did the family visit? Were we able to transfer or complete ADLs on a normally difficult resident? SHARE our success stories! Examples: CNAs from each shift present. Primary Nurse from both shifts present during report. The nurse will interject and add information as the report is flowing. "I am reporting on __________," "____________ is receiving skilled nursing care for____ ______." Acute problems, "__________ is not feeling well today, she ate poorly, drank well, but spent a lot of time in bed. She is a skin risk, so we have been turning her every two hours. She is due to be turned directly after report." (So IMPORTANT to state when someone was last turned!!) Risks: "Resident is at risk for ________________." Include CHANGES and the PLAN for the resident. (See Above) Skin Risks Fall Risks Seizure Risks Weight/nutrition Risks and/or appetite: New Behaviors/Challenging Behaviors Pain Share WINS Example: "I am reporting on Mrs. Jones. She is at risk for weight loss, but ate 100% of breakfast and lunch today. She is drinking well. She is at risk for skin breakdown, her heel hover boots and elbow protectors are on. Her family was in to visit at lunch." Editor's note: Provided courtesy of MaineGeneral Rehabilitation & Nursing Care. (The full form includes additional examples of what CNAs should report.)
MDS Alert
- MDS 3.0:
Don't Delay: Nailing Down the Latest RAI Manual Revisions Will Pay
Make sure you're using these instructions now. Wondering if you can code ADL help provided [...] - Clip 'N Save:
CMS Pumps Up Instructions for Coding Isolation for Infection
You can still code isolation if the resident goes offsite for these reasons. The revised [...] - MDS ComplianceL:
Sidestep Unnecessary Dashes on the MDS
Overuse has raised a flag for CMS, says agency official. A CMS official recently gave [...] - SNF Prospective Payment System:
CMS' PPS Proposal Targets Rehab With These Key Measures
The Change of Therapy OMRA could rock the payment boat. Beware: You could soon have [...] - Quality Improvement Trends:
Follow These Facilities' Lead to Take the MDS 3.0 and Care to a New Level
Including mood items on the daily CNA documentation form helped this care team assist a [...] - WHAT DO YOU THINK?
Should a Facility Code Pain Education as a Non-pharmacological Pain Remedy at J0100C? Answer: "The [...] - Prospective Payment System:
Brace for Briefer ARD Windows: Expert Provides Tips for Managing the Potential Change
This aspect would remain the same, says CMS official. The FY 2012 proposed SNF PPS [...] - Tool:
Nursing Facility Highlights Must-Dos for Shift Report
Spelling out the process helps staff know what to report. MaineGeneral Rehabilitation & Nursing Care [...] - MDS, Compliance & Clinical News
Your facility's HIPAA disclosure obligations could soon increase. A proposed Health & Human Services rule [...] - MDS 3.0 Coding
Review the Staff Assessment for Pain J0800. Indicators of Pain or Possible Pain in the [...]