State surveys bring butterflies and stress to long term-care staff and administration. In order to survive these events, facilities must design processes that will focus on issues likely to arise during the survey. At the Delaware Valley Veterans Home in Philadelphia, we use a quality indicator meeting to address these issues.
We use resources such as the quality indicator/quality measure (QI/QM) reports and the roster matrix to review treatments and services provided to our residents. We have had surveyors question how the facility addresses devices which are used for safety and therapeutic needs, such as wheelchairs, geriatric chairs, seat belts, leg rests, walkers, and lap trays. We created a device (restraint) review program which is overseen by a multidisciplinary team that includes the QA nurse, DON/ADON, physical/occupational therapist, charge nurse for each unit, physician, RNAC, and social worker. Since the institution of the meeting, this program has evolved to include many QI/QM. Recently, we have had both a state survey and Veterans Administration survey during which time we used the tool from this meeting to demonstrate that we were reviewing and adjusting various treatments for residents. Each time the surveyors were impressed by this QI meeting.
We nicknamed this meeting “Mega Meeting.” QI/QMs, such as significant weight loss, pressure sores, declines in activities of daily living, restraints, psychiatric medications, falls, and elopement risk are discussed. We use a tool that was created by our QA nurse. Prior to this meeting, data must be accumulated about weights, wounds, devices (such as side rails, wheelchairs, geriatric chairs, bed alarms, chair alarms, seat belts for wheelchairs, lap trays), psychiatric medications (antipsychotics, antidepressants, anxiolytics, and hypnotics), most recent falls, and up-to-date elopement assessments. Once this information is assembled, we usually convene our meetings on the first or second week of the month. The residents we select for review are generated from those that are due for an MDS assessment.
Starting with dietary and weight issues, significant weight losses (5% or greater) are reviewed with attention to whether the patient needs various interventions or testing. If determined that the resident's intake is abnormal, we must then differentiate between causes such as stroke, infection, dementia, and dysphagia. Furthermore, we may request a speech consult to rule out swallowing difficulties. As a result of evaluation, supplements, such as protein drinks, may be given as well as orders for labs, such as albumin and prealbumin to monitor nutritional status during interventions. If there is a possibility that the decline is due to infection, we may order chest x-rays or urine studies. If it appears that the resident has severe dysphasia, then a family meeting is required to determine level of care (peg tube or supportive care only). Included in this meeting are all residents receiving tube feeds and modified diets (puréed or mechanical soft with thickened liquids [figure 1]).
Next, wounds are addressed. Our facility uses a wound care team that performs weekly rounds on all residents currently having wounds. At this time, the team assesses and reassesses all wounds and current treatments. Our wound care specialist brings this information to the Mega Meeting as well as the Braden scores for all those residents being reviewed. If the Braden score is low, we then address the problems with our internal process, such as the toileting program or the skin check program. If it is a pressure or vascular wound which fails to heal, we need to review Doppler studies, nutritional status (intake and protein stores), or the presence of severe edema. During this period we may further add devices, such as lambskin boots, multipodis boots, an air mattress, or other off-loading devices. Nutritional status is again reviewed as it relates to wound healing and protein supplements may be added to maximize healing even though the resident's protein stores may be adequate (figure 2).
Therapies, restorative nursing
Next, the need for therapies and restorative nursing are assessed. If the resident has limited strength or range of motion in legs or arms for example, the resident needs quarterly screens by the respective therapist. If residents have dysphasia, modified diets, or aphasias, then a speech screen is required to determine speech therapy needs. We review whether the resident is on restorative feeding, progressive restorative for ambulation, or preventative restorative for contracture prevention. These issues, along with the above QI/QM issues, are documented in the care plan if they are considered significant (figure 3).