AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Electronic Reports
On-Time Nutrition Risk Reports
There are two Nutritional Risk Reports: medium-risk and high-risk resident reports.
Table 1: Sample On-Time Nutrition Risk Report: High Risk
Resident | Room Number | Decreased Intake: First Date | Avg. Meal Intake % 3/1/14 | Avg Meal Intake % 3/8/14 | Avg Meal Intake % 3/15/14 | Avg Meal Intake % 3/22/14 | Diet / Order Date* | Tube Feed | Avg. Supplement Intake %* | Weight Change lb | Most Recent Ulcer Access Date | # Pr Ulcers |
---|---|---|---|---|---|---|---|---|---|---|---|---|
A | 001 | 03/23 /2014 | 50 | 41 | 36 | 29 | Pureed 2/28 /14 |
X | -1.5 | 3/20/14 | 2 | |
B | 002 | 03/26 /2014 | 64 | 52 | 47 | 45 | Mech 1/22 /14 |
50% | -3.3 | 3/20/14 | 1 | |
C | 003 | 03/29 /2014 | 74 | 62 | 58 | 42 | Reg 3/22 /14 |
-1.5 | ||||
D | 004 | 03/24 /2014 | 86 | 89 | 71 | 59 | Reg 12/3/13 |
-2.5 |
*Columns added in 2014.
Note: Only a report for high-risk residents is shown. Separate high and medium Nutrition Risk Reports can be produced.
Report Purpose
Nutrition Risk Reports (high- and medium-risk residents) provide the clinician with an overall portrait of resident nutrition risk status and identify residents with subtle changes or declines in nutritional status so that actions may be taken before large weight losses occur and nutrition problems develop that can affect skin integrity. The user can see residents with subtle declines in meal intake and additional details about the resident at a glance.
The report can help answer the following questions:
- What is the resident's diet? How long has the resident been on this diet?
- Does the diet need to be changed?
- Is the resident on tube feeding? If no, then an order can be considered.
- Is the resident on supplements? If yes, the average supplement intake will display. If the supplement intake is insufficient, then care plan interventions can be considered. If there is no order for supplements, then an order to start supplements can be considered.
- Is the resident also experiencing weight loss? This report can be paired with the On-Time Weight Summary Report to see additional detail about resident weight values and trends.
Report Description
The weekly reports display resident-level nutrition information for a single nursing unit: average weekly meal intake for 4 consecutive weeks, diet, tube feeding status, average supplement intake for the report week, and recent weight change. The reports sort residents into high and medium nutritional risk.
The reports use two criteria to determine level of nutritional risk; residents meeting one or both criteria will display on either the high or medium risk report, never both.
Nutrition Risk Criteria
- If meal consumption is 50 percent or less for two meals in one day at least one time during the report week.
- If there is any weight loss during the report week, determined by subtracting current week's weight from most recent weight.
Table 2: Criteria and Level of Risk
Nutrition Risk Report | Nutrition Risk Criteria | |
---|---|---|
Decreased Meal Intake | Weight Loss | |
Medium Risk Report* | X | |
Medium Risk Report | X | |
High Risk Report | X | X |
* Residents at high and medium risk display on separate report tables.
Users and Potential Uses
The table below displays potential users of the Nutrition Risk Reports and potential uses. There are no standard nutrition meetings or workflows across nursing homes and these may even vary within an organization; therefore, users are provided with optional strategies to integrate the report into daily practice.
Table 3: On-Time Nutrition Risk Report Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | Dietary department staff | Dietary Department Internal Review |
3 | MDS nurse | MDS Assessment Documentation |
4 | Nurse manager, charge nurse | Nurse Shift Change Report |
5 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
6 | Charge nurse, wound nurse, CNA | Skin Rounds |
7 | Charge nurse, dietician, CNA, and others (e.g., wound nurse, social service, MDS nurse, etc.) | Weekly Nutrition Risk Huddle |
8 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director or Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk, or Nutrition Risk, etc.) |
9 | DON or ADON, nurse manager, wound nurse, physician, NP, QI director | Weekly Wound Review Meetings* |
10 | DON, Nurse manager, wound nurse, wound physician, NP, CNA | Wound Rounds |
On-Time Weight Summary Report
Table 4: Sample On-Time Weight Summary Report
Resident Name | Resident ID | Weight 180 Days Prior | Weight 90 Days Prior | Weight 30 Days Prior | Weight For Week 5/8/14 Week4 | Weight For Week 5/15/14 Week3 | Weight For Week 5/22/14 Week2 | Weight For Week 5/29/14 Week1 | Weight Change lbs | ≥2% Wt. Loss (from previous week) | ≥5 lb Wt Loss in Prior 30 days | ≥5% Wt Loss in Prior 30 Days | ≥5% Wt Loss in Prior 30 Days (Any) | ≥7.5% Wt Loss in Prior 90 days | ≥10% Wt Loss in Prior 180 Days |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
A | #####1 | 285.3 | 275.0 | 254.5 | 252.4 | 256.1 | 251.7 | 253.8 | 2.1, 5/19 /14 | 8.0% | 11.3% | ||||
B | #####2 | 172.1 | 175.3 | 180.0 | 180.0 | 170.0 | 181.0 | 171.0 | -10.0, 5/19 /14 | 5.5% | 9.0 | 5.6% | 5.6%, 5/12/14; 5.5%, 5/27 /14 |
Note: All weight loss calculations are point to point unless "Any" is indicated. Date indicates when the weight change is first identified.
Report Purpose
The Weight Summary Report provides trended views of resident weight values for up to 180 days. The report was developed with registered dietitians (RDs) and incorporates calculations used by RDs to conduct routine assessments, engage in care planning, and complete MDS assessments.
Report Description
The Weight Summary Report displays 4 weeks of trended weight information for each resident, calculates weight changes, and displays whether there have been measurable weight loss percentages (more than 2 percent, 5 percent, 7.5 percent, and 10 percent) for the past 7, 30, 90, and 180 days).
Weights are calculated in two ways:
- Point-to-Point: using two data points, to determine if weight loss occurred.
- Any Weight Loss: using multiple weight comparisons within a specified period to identify "Any" weight loss within the period.
Users and Potential Uses
All clinical staff members are potential users of this report. The Weight Summary Report is often used as a companion report to the Nutrition Risk Reports during multidisciplinary team meetings.
The table below displays potential users of the Weight Summary Report and potential uses.
Table 5: On-Time Weight Summary Report Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | Dietary department staff | Dietary Department Internal Review |
3 | MDS nurse | MDS Assessment Documentation |
4 | Administrator, DON, nurse managers, Dietary director, Rehab director and other departmental directors | Risk Management Meetings |
5 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
6 | Charge nurse, wound nurse, CNA | Skin Rounds |
7 | Charge nurse, dietician, CNA, and others (e.g., wound nurse, social service, MDS nurse, etc.) | Weekly Nutrition Risk Huddle |
8 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director or Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk, or Nutrition Risk, etc.) |
9 | DON or ADON, nurse manager, wound nurse, physician, NP, QI director | Weekly Wound Review Meetings |
10 | DON, Nurse manager, wound nurse, wound physician, NP, CNA | Wound Rounds |
On-Time Pressure Ulcer Trigger Summary Reports
There are two Pressure Ulcer Trigger Summary Reports: resident level and unit level.
Table 6: Sample On-Time Pressure Ulcer Trigger Summary Report (Resident Level)
Name | Resident ID | Wt Loss ≥5% Prior 30 Days (Any) | Wt Loss ≥7.5% in Prior 180 Days (Point-to-Point) | Wt Loss ≥10% in Prior 180 Days (Point-to-Point) | 2 Meals ≤50% in 1 Day | Weekly Meal Intake Average <50% | Daily Urinary Incont | >3 Days Bowel Incont | Foley Catheter | Current Pressure Ulcer | # of Triggers Last Week | # of Triggers This Week |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Res1 | 0001 | X | X | X | X | 3 | 4 | |||||
Res2 | 0002 | X | - | X | X | X | 2 | 4 | ||||
Res3 | 0003 | X | X | X | X | X | 5 | 4 | ||||
Res4 | 0004 | X | X | X | X | 0 | 4 | |||||
Res5 | 0005 | X | - | X | X | X | 2 | 4 | ||||
Res6 | 0006 | X | - | - | X | X | 0 | 3 | ||||
Totals | 1 | 1 | 2 | 3 | 1 | 4 | 6 | 5 | 1 |
On-Time Pressure Ulcer Trigger Summary Report (Resident Level)
Report Purpose
This report provides enough information for the clinician to identify residents at risk due to a high number of recent risk increases from the prior week. Risk is based on eight factors associated with pressure ulcer development that may "trigger" the development of a pressure ulcer. For example, a resident having two triggers the prior week and five in the current week would suggest a dramatic increase in risk to develop a pressure ulcer, prompting questions such as:
- What can explain this change?
- Is the entire care team aware of this increasing risk?
- Has the care plan been updated to reflect this change?
- Do care plan interventions address the risk identified on the report or the changes that the clinician may discover during a followup assessment?
The information on the report does not display recommended followup but it does give enough information to prompt the clinician to conduct a followup assessment, collaborate with multiple disciplines, confirm that existing care plan interventions are appropriate, and communicate the changes in risk to the entire care team.
Report Description
The report displays residents who have at least one trigger activated during the report week presented in descending order of total number of pressure ulcer triggers for the report week. The report displays the prior week trigger totals and the current total, and provides a weekly snapshot of a resident's risk for pressure ulcer development. These triggers are derived primarily from electronic CNA documentation.
Users and Potential Uses
The table below displays potential users of the On-Time Trigger Summary Report and Potential Uses.
Table 7: On-Time Pressure Ulcer Trigger Summary Report (Resident-Level View) Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | CNA, charge nurse | CNA Shift Change Report |
3 | MDS nurse | MDS Assessment Documentation |
4 | Rehab department staff | Rehab Department Internal Review |
5 | Restorative department staff | Restorative Care Internal Review |
6 | Nurse manager and Rehab director or therapist | Weekly Risk Huddle for Nurse and Rehab |
7 | Charge nurse, dietician, CNA, and others (e.g., wound nurse, social service, MDS nurse, etc.) | Weekly Nutrition Risk Huddle |
8 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director or Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk or Nutrition Risk, etc.) |
9 | DON or ADON, nurse manager, wound nurse, physician, NP, QI director | Weekly Wound Review Meetings |
Table 8. On-Time Pressure Ulcer Trigger Summary Report (Unit Level)
Pressure Ulcer Triggers | Week 4 5/10/14 |
Week 3 5/17/14 |
Week 2 5/24/14 |
Week 1 5/31/14 |
---|---|---|---|---|
Wt Loss ≥ 5% in Prior 30 Days (Any) | 1 (3%) | 2 (6%)(a) | 1 (3%)(b) | 1 (3%) |
Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point) | 1 (3%) | 1 (3%) | 1 (3%) | 1 (3%) |
Wt Loss ≥10% in Prior 180 Days (Point-to-Point) | 1 (3%) | 2 (6%)(a) | 1 (3%)(b) | 2 (3%)(a) |
2 Meals ≤50% in 1 Day | 5 (14%) | 4 (11%)(b) | 4 (11%) | 7 (20%)(a) |
Weekly Meal Intake Average <50% | 3 (9%) | 3 (9%) | 2 (6%)(b) | 3 (9%)(a) |
Daily Urine Incontinence | 2 (6%) | 3 (9%)(a) | 3 (9%) | 5 (14%)(a) |
>3 Days Bowel Incontinence | 5 (14%) | 4 (11%)(b) | 3 (9%)(b) | 7 (20%)(a) |
Foley Catheter | 8 (23%) | 7 (20%)(b) | 5 (14%)(b) | 8 (23%)(a) |
Current Pressure Ulcer | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) |
Note: The report has been coded with (a) representing an increase, (b), a decrease in weekly pressure ulcer trigger prevalence.
Report Purpose
The unit level section of the report is used to monitor the overall prevalence and trends of pressure ulcer triggers on a specific nursing unit. This information may be useful for program monitoring and planning or identifying inservice needs of staff.
Report Description
The unit-level view displays the number of residents (and percentage of the total nursing unit census) who have met each pressure ulcer risk criteria for 4 consecutive weeks. The report displays an indicator or color-coding to show improvement (green) or decline (red) in values from the prior report week. The type of indicator to use for improvement/decline depends on the EMR vendor. The vendor may offer table results in a graphic display as well.
Users and Potential Uses
The table below displays potential users of the On-Time Trigger Summary Report and potential uses.
Table 9: On-Time Pressure Ulcer Trigger Summary Report (Unit Level) Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Restorative department staff | Restorative Care Internal Review |
2 | Administrator, DON, nurse managers, Dietary director, Rehab director and other departmental directors | Risk Management Meetings |
3 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
On-Time Risk Change Report: Resident Changes and Declines From Prior Week
Table 10: Sample On-Time Risk Change Report: Resident Changes and Declines From Prior Week
Name | Room Number | Nutrition Risk | Change Within 7 Days | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Increase in Incontinence | ADL Decline# | ≥3 Behaviors | Pressure Ulcer | Health Status# | |||||||||
Decreased Meal Intake + Weight Loss |
Decreased Meal Intake | Weight > Loss ≥5% in Prior 30 Days | Urine | Bowel# | Bed Mobility | Transfer | Toileting | Change in Behavior Types From Prior Week | Worsening Ulcer | New Ulcer | Acute Change in Status | ||
Resident 1 | 202 | X | 7* | ||||||||||
Resident 2 | 212 | X | X | X | X | X | |||||||
Resident 3 | 217 | X | X | X | 3 | ||||||||
Resident 4 | 229 | X | X | ||||||||||
Resident 5 | 231 | X | X | X | |||||||||
Resident 6 | 242 | X | |||||||||||
Resident 7 | 243 | 4 | X |
Note: If three or more behaviors for a resident were documented during the current week then the number of behaviors will display.
* indicates new behavior in current week.
# indicates column added in 2014.
Report Purpose
The On-Time Risk Change Report: Resident Risk and Declines From Prior Week (formerly called On-Time Priority Report) provides a priority list of residents with week-to-week changes and/or declines in factors associated with pressure ulcer risk, nutrition, and weight loss, and it alerts the nurse to new or worsening pressure ulcers. The Risk Change Report provides a bit more detail on risk changes than the On-Time Trigger Report without providing too much information to be absorbed by the clinical team.
The Risk Change Report prompts the clinician to follow up on potentially subtle changes that may not have been identified using other tools to help answer or generate the following questions:
- Why did the resident flag for increase in urinary incontinence?
- Is this a subtle or dramatic change?
- Has this been addressed?
- Was it communicated on the 24-hour report?
- What resident behaviors have changed from the prior week? Are these new behaviors? Has there been follow-up to a potential change in behavior? What is the underlying cause?
- Is the dietitian aware that the latest wound assessment indicates a worsening in pressure ulcer status?
Report Description
The On-Time Risk Change Report uses six criteria to signal potential risk for new pressure ulcer development:
- Nutrition risk (decline in meal intake and weight loss).
- Increase in bladder and bowel incontinence.
- Decline in three ADLs (bed mobility, transfer, and toileting).
- Behavior (If three or more different behaviors for a resident were documented during the current week, then the number of behaviors will display. Clinicians report that indicators of an increase in behaviors or change in types of behaviors from the prior week serve as an early warning of a change in resident condition that should be further assessed to determine underlying cause).
- Current pressure ulcer status (new or worsening ulcer); and
- Acute change in health status.
Residents with a change in at least one of these criteria from the previous week will display on the report. All documentation is captured from electronic CNA documentation except "new or worsening pressure ulcer," which is captured from nurse weekly wound assessments, and "acute change in health status," which is captured from nurse documentation of resident change in condition or from the nurse electronic 24-hour report. Examples of an acute change in health status are elevated temperature with blood cultures obtained or new urinary tract infection with new order for antibiotics. Because EMR vendor functionality varies, implementers will determine the most appropriate data source that indicates an acute change in the resident's health status.
Users and Potential Uses
The table below displays potential users of the On-Time Risk Change Report.
Table 11: On-Time Risk Change Report Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | Nurse, CNA | CNA Shift Change Report |
3 | Dietary department staff | Dietary Department Internal Review |
4 | MDS nurse | MDS Assessment Documentation |
5 | Nurse manager, charge nurse | Nurse Shift Change Report |
6 | Rehab department staff | Rehab Department Internal Review |
7 | Restorative department staff | Restorative Care Internal Review |
8 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
9 | Charge nurse, wound nurse, CNAs | Skin Rounds |
10 | Nurse manager and Rehab director or therapist | Weekly Risk Huddle for Nurse and Rehab |
11 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director or Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk or Nutrition Risk, etc.) |
12 | DON or ADON, nurse manager, wound nurse, physician, NP, QI director | Weekly Wound Review Meetings |
13 | DON, Nurse manager, wound nurse, wound physician, NP, CNA | Wound Rounds |
Intervention History for Nutrition Risk Reports
There are two Intervention History for Nutrition Risk Reports: high-risk and medium-risk resident reports.
Table 12: Sample On-Time Intervention History for Nutrition Risk Report: High Risk
# | High-Risk Residents | Room | Diet | Diet Changes | Supplements | PT | OT | Speech | Social Services | Psych | Gastroenterology | Hospice | Seen by: MD / PA or NP | Chemistry | Microbiology | Hematology |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Brown, M | 201 | Regular | 1/3 /14 | 10/4/13 | 1/2 /14 | 1/2 /14 | 1/2 /14 | 11/27/13 | 7/3/13 | 7/3/13 | |||||
2 | White, D | 209 | Regular | 10/20/13 | 9/2/13 | 10/18/13 | 11/2/13 | 12/27/13 | 11/13/13 | 11/13/13 | 11/13/13 | 11/13/13 | 11/13/13 | |||
3 | Green, D | 212 | Pureed | 12/23/13 | 12/30/13 | 1/2 /14 | 1/2 /14 | 12/18/13 | 12/18/13 | |||||||
4 | Orange, L | 221 | NPO | 1/5 /14 | 12/15/13 | 1/3 /14 | 1/3 /14 | 6/2/13 | 6/2/13 | |||||||
5 | Pink, S | 222 | Diabetic | 7/22/13 | 12/31/13 | 7/25/13 | 2/18/13 | 2/18/13 | ||||||||
6 | Silver, C | 237 | Low NA | 12/18/13 | 11/29/13 | 5/12/13 | 5/12/13 | 5/12/13 | ||||||||
7 | Reddish, R | 238 | Regular | 9/6/13 | 12/4/13 | 9/6/13 | 12/4/13 | 12/4/13 | ||||||||
8 | Black, B | 240 | Pureed | 10/3/13 | 1/2 /14 | 2/18/13 | 12/4/13 | 12/4/13 |
Note: Intervention History for Nutrition Risk Reports is a new report that was added in 2014. Only the report for the high-risk residents is shown. Separate reports for high and medium nutritional risk residents can be produced.
Report Purpose
The On-Time Intervention History for Nutrition Risk Reports display for each resident at high or medium nutrition risk relevant interventions associated with nutritional risks. Each report provides a history of interventions for residents at nutritional risk and "tells a story" that a clinician can use to consider next steps. In reviewing the report, the clinician can easily see what has been done and when; likewise, the clinician can easily see what has never been ordered. Having these dates at hand eliminates the need for the clinician to manually review the medical record in search of prior interventions for nutrition risk.
These orders support nurse decisionmaking as next steps are considered. For example, knowing the resident's current diet, how long the resident has been on the current diet, the presence or absence of supplements, the time that has passed since the last consults for physical therapy (PT), occupational therapy (OT), or speech therapy, or if consults were ever obtained, all contribute to decisionmaking and enhance care planning as next steps are considered. Knowing the dates of latest lab orders, even without knowing the actual values, contributes to the nurse's ability to formulate a plan and focus next steps beyond followup assessment and chart review. Seeing what has been done and when contributes to considering what needs to be done and where to focus a more indepth chart review.
Note: If the EMR vendor is interfaced with a lab information system, then actual lab values can display.
Report Description
The On-Time Intervention History for Nutrition Risk Reports are companion reports to the Nutrition Risk Reports. The report displays the same residents at high or medium nutritional risk that display on the Nutrition Risk Reports plus additional information that informs the clinician when physician orders and interventions were initiated. The report captures the following information from EMR physician orders:
- Resident nutrition, including current diet and diet order date, supplement order date, referral types, and dates when ordered. Referral types include PT, OT, speech therapy, social services, psych, and gastroenterology.
- Dates also provided include when hospice services began; when resident was last seen by the attending physician, nurse practitioner (NP), or physician assistant (PA); when resident was evaluated by therapy or specialists (if ordered) and had chemistry, microbiology, and hematology lab work.
Users and Potential Uses
The table below displays potential users of the On-Time Nutrition Risk Intervention History Report and potential uses.
Table 13: Intervention History for Nutrition Risk Report: Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | Dietary department staff | Dietary Department Internal Review |
3 | MDS nurse | MDS Assessment Documentation |
4 | Administrator, DON, nurse managers, Dietary director, Rehab director and other departmental directors | Risk Management Meetings |
5 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
6 | Charge nurse, dietician, CNA, and others (e.g., wound nurse, social service, MDS nurse, etc.) | Weekly Nutrition Risk Huddle |
7 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director or Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk, or Nutrition Risk, etc.) |
On-Time Resident Clinical, Functional, and Intervention Profile Report
The On-Time Resident Clinical, Functional, and Intervention Profile Report is a new report that was added in 2014.
Table 14: On-Time Resident Clinical, Functional Status, and Intervention Profile Report
Week Ending | |||||
---|---|---|---|---|---|
4/6/14 | 4/13/14 | 4/20/14 | 4/27/14 | ||
Vital Signs | Number of pressure ulcers | 0 | 1 | 2 | 2 |
Temperature | 99.2 | ||||
Pulse | 82 | 88 | 90 | 100 | |
Respirations | 20 | 20 | 20 | 20 | |
Blood pressure | 102/58 | 110/60 | 102/58 | 120/88 | |
O2 saturation | 96 | 97 | 98 | 88 | |
Weight | Weight in pounds | 149.2 | 144 | ||
Weight date | 3/26 /14 | 4/23 /14 | |||
Nutrition / Vitamins & Supplements | Diet | Pureed | Pureed | Pureed | Clear liquids |
Tube feeding | No | No | No | No | |
Supplements | No | Ensure | Ensure | Ensure | |
Multivitamin | No | No | No | Yes | |
Vitamin C | No | Yes | Yes | Yes | |
Arginaid | No | No | No | No | |
Zinc | No | No | No | No | |
Protein | No | No | Yes | Yes | |
Weekly average meal intake—percent | |||||
Breakfast | 88 | 78 | 62 | 75 | |
Lunch | 79 | 74 | 25 | 25 | |
Dinner | 65 | 55 | 45 | 35 | |
Nutritional supplement—percent | |||||
Breakfast | 25 | 50 | 25 | 25 | |
Lunch | 25 | 25 | 25 | 25 | |
Dinner | 0 | 25 | 0 | 0 | |
Bowel | Habits | Continent | Continent | Incontinent | Incontinent |
Loose stool | No | No | Yes | Yes | |
Incontinence | |||||
# shifts/week | 0 | 0 | 12 | 18 | |
Daily incontinence | X | ||||
3 days without BM | X | X | |||
Bladder | Habits | ||||
Catheter | Condom | No | No | Foley | |
Ostomy | No | No | No | No | |
Incontinence | |||||
# shifts/week | 9 | 12 | 12 | 14 | |
Daily incontinence | No | No | Yes | Yes | |
Did not void # shifts/week | 0 | 0 | 0 | 1 | |
Restorative | Bowel | No | No | No | No |
Bladder | No | No | Yes | Yes | |
Eating | No | No | No | No | |
Mobility | No | No | No | No | |
Self-Performance/Support Provided2 | Bed mobility | EA/1 | EA/1 | EA/1 | EA/2 |
Transfer | EA/1 | EA/1 | EA/1 | EA/2 | |
Locomotion | EA/1 | EA/1 | EA/1 | EA/2 | |
Dressing | LA/set up | EA/1 | EA/1 | EA/1 | |
Eating | LA/set up | EA/1 | EA/1 | EA/1 | |
Personal hygiene | LA/set up | EA/1 | EA/1 | EA/1 | |
Toileting | EA/1 | EA/1 | EA/1 | EA/2 | |
Labs1 | Pre Albumin (19.5-35.8 mg/dL) | 33.0 | 21.6 | ||
Albumin (3.4-5.4 g/dL) | 3.4 | 3.6 | 5.8* | 6.2* | |
Sodium (135-145 mEq/L) | 128* | 122* | 114* | 120* | |
Potassium (3.5-5.2 mEq/L) | 4.0 | 4.3 | 4.4 | 4.3 | |
Creatinine (0.7-1.3 mg/dL) | 0.6* | 0.7 | 1.0 | 1.8* | |
BUN (6.0-20.0 mg/dL) | 6.0 | 6.2 | 6.0 | 6.1 | |
Transferrin (20-50%) | 20 | 25 | 35 | 35 | |
Bed Surfaces | Air fluidized surface | X | X | X | X |
Dynamic/alternating pressure | |||||
Low air loss | |||||
Replacement mattress | |||||
Chair Surfaces | Fluid filled or gel cushions | X | X | X | X |
Foam cushions | |||||
Combination cushions | |||||
Other | Heel boots | X | X | X | X |
1 Lab normal value ranges used by the facility in parentheses.
* Indicates abnormal value.
2These abbreviations are based on MDS 3.0 ADL coding: Self-Performance—EA= extensive assistance; LA = limited assistance; and Total = total dependent; the abbreviation after the slash represents ADL support provided—set up=set up help only, 1 or 2 = how many staff provide physical assistance.
Report Purpose
The On-Time Resident Clinical, Functional, and Intervention Profile Report displays a 4-week view of the resident's clinical status that can be accessed by any clinical staff interested in reviewing historic data. Resident information is summarized and displayed in a useful format and eliminates the need for licensed staff to retrieve resident information from multiple electronic or paper sources or a combination of both. Trended data allow the clinician to spot subtle upward or downward trends that may not be apparent during daily or shift review.
QI teams may want to access trended information to gain insights into the status of a resident in the 4 weeks leading up to pressure ulcer development. Insights may lead to adjustment in the care plan to help prevent additional pressure ulcers from forming. For example:
- Was there a gradual and steady decline in average meal intake percentages? If yes, when did it start?
- Did intake at one meal decline more than at other meals? Can the CNA offer insights?
- Was there an indication of a gradual decline or an increased dependence on staff for certain aspects of ADLs? If yes, could these indicators have been identified before the ulcer developed?
- Are there opportunities to improve specific processes within a nursing unit or facilitywide?
- Could any bed or chair supportive surfaces have been implemented sooner? If yes, are there opportunities to improve communication or information flow to rehabilitation services?
Report Description
This report displays 4 weeks of clinical data for a single resident that is captured from electronic CNA daily charting, physician orders, and lab result values. Information from CNA documentation includes resident weight and vital signs; weekly average meal intake percentages for breakfast, lunch, and dinner; bowel and bladder documentation; and activities of daily living (ADLs). Information from physician orders includes pressure ulcer prevention devices (e.g., bed and chair surfaces) and nutrition orders (e.g., diet order, tube feeding, and supplements).
Users and Potential Uses
The table below displays potential users and uses of the On-Time Resident Clinical, Functional, and Intervention Profile Report.
Table 15: On-Time Resident Clinical, Functional, and Intervention Profile Report Users and Potential Uses
Users | Potential Uses | |
---|---|---|
1 | Multidisciplinary team | Care Plan Meetings |
2 | Dietary department staff | Dietary Department Internal Review |
3 | MDS nurse | MDS Assessment Documentation |
4 | Restorative department staff | Restorative Care Internal Review |
5 | Administrator, DON, nurse managers, Dietary director, Rehab director and other departmental directors | Risk Management Meetings |
6 | DON or ADON, nurse manager, wound nurse, QI director, QI staff | Root Cause Analysis for New Pressure Ulcers |
7 | DON or ADON, nurse manager, wound nurse, dietician, Rehab director/Rehab therapist | Weekly Risk Meetings (e.g., Pressure Ulcer Risk, or Nutrition Risk, etc.) |
8 | DON or ADON, nurse manager, wound nurse, physician, NP, QI director | Weekly Wound Review Meetings |
Completeness Report
Table 16: Sample On-Time Completeness Report: Day Shifts
Documentation Section | 5/29/13 | 6/5/13 | 6/12/13 | 6/19/13 |
---|---|---|---|---|
Meal Intake Breakfast | 98.2 | 97.2 | 99.1 | 99.4 |
Meal Intake Lunch | 88.4 | 90.2 | 92.2 | 96.6 |
Bowels | 67.6 | 74.9 | 66.2 | 58.3 |
Bladder | 54.8 | 61.7 | 78.2 | 86.9 |
Behaviors | 53.1 | 69.9 | 87.1 | 91.0 |
Report Purpose
The Completeness Report is used to check CNA documentation to determine how much of the data needed for report calculations may be missing. Because of the advances EMR vendors have made in the last decade in providing mechanisms for users to monitor CNA documentation completion, the report is now an optional report for implementers.
With this report, nurses can review trends to determine if CNAs are documenting better, worse, or about the same as previous weeks. By displaying completeness percentages by specific areas of charting, nurse managers and staff educators can focus education and target inservice training on areas with low completion rates. Ongoing use of the report provides feedback to staff on CNA progress. The shift-detail view displays documentation completeness for each shift.
Report Description
The Completeness Report provides a trended view of completeness rates, displaying 4 weeks of data, including the current week and previous 3 weeks. The report provides nursing home staff with a mechanism to audit the completeness of CNA documentation on a weekly basis at the facility and nursing-unit level. The Completeness Report displays weekly documentation percentages for the documentation elements required for the On-Time Program:
- Meal intake.
- Bowel.
- Bladder.
- Behavior.
Users and Potential Uses
This report is used by clinical staff during weekly huddles to review CNA accuracy and completion rates.