Improving Patient Safety in Long-Term Care Facilities

Appendix 1-A. Suggested Slides for Module 1

Slide 1

Knowledge objectives

Participants will be able to understand:

  • Why detecting change is important.
  • How to know a resident's normal (baseline) condition.
  • How to watch for change.
  • How the Early Warning tool and SBAR tool work.
  • How to communicate about change.

Slide 2

Performance objectives

Participants will be able to:

  • Summarize a resident's normal (baseline) condition for other team members.
  • Identify whether changes in a resident's condition are important or not important.
  • Promote behaviors that improve change detection.

Slide 3

Performance objectives (continued)

Participants will be able to:

  • Use the Early Warning tool and SBAR tool.
  • Decide when to report or when to ask for help when observing changes in a resident's condition.

Slide 4

Case Study: Ms. A

  • 79-year-old frail woman.
  • Admitted after hip fracture, followed by hospital and rehabilitation stays.
  • Walks with a walker.
  • Daughters visit on weekends.
  • Liquid diarrhea.
  • Falling blood pressure, rising heart rate.
  • Fever of 102o F.
  • Transferred to the hospital intensive care unit.

Slide 5

Case Study: Ms. A

  • How did Ms. A get so sick with only diarrhea?
  • When might you have decided to report it?
  • What would you have reported and to whom?

Slide 6

Key Lessons

  • Learn to notice a change early.
  • Not reporting a change can lead to other things going wrong.
  • The sooner something is done, the better.

Slide 7

Role of Nursing Assistants and Licensed Nurses

  • Your role in a long-term nursing center is important.
  • Nursing assistants see the residents most often.
  • Residents in long-term care depend on nursing assistants to notice changes.
  • Nursing assistants are the eyes, ears, and hands of the care team.

Slide 8

Detecting Change

  • Know the resident's normal (baseline) condition.
  • Note the resident's ability to move around.
  • Know how the resident does with activities of daily living.
  • Know the resident's preferences for activities, eating, and dressing.

Changes from the resident's normal condition can signal a medical change.

Slide 9

Recognizing Changes

  • Do a shift-to-shift comparison.
  • Make sure the needed equipment is available.
  • See if a change occurred in any of the resident's other vital signs.
  • Check the resident's records of urination and bowel movements.

Slide 10

Registered Nurse's Assessment

  • Ask the resident how he or she feels, even if the resident is confused or seems to be "out of it."
  • Ask the resident how and when the symptoms began.
  • Take the resident's vital signs again.
  • Perform a general exam; assess level of consciousness and cognitive and physical function.
  • After the assessment, organize the information and report it to the resident's nurse practitioner or doctor, if warranted.
  • Several tools to help with evaluating mental status can be found in the MDS.

Slide 11

Top 12 Changes in Residents

Physical Changes:

  • Walking.
  • Urination and bowel patterns.
  • Skin.
  • Level of weakness.
  • Falls.
  • Vital sign.

Non-Physical Changes:

  • Demeanor.
  • Appetite.
  • Sleeping.
  • Speech.
  • Confusion or agitation.
  • Resident complaints of pain.

Slide 12

Watch for Physical Changes

  • Walking—e.g., how much assistance the resident needs with walking.
  • Urination and bowel patterns—e.g., the resident is urinating less frequently.
  • Skin—e.g., the resident's skin is puffy.
  • Level of weakness—e.g., the resident is having difficulty lifting his or her arm.
  • Falls—e.g., the resident reaches for objects when in a wheelchair.
  • Vital signs—e.g., the resident is breathing faster than normal.

Slide 13

Watch for Non-physical Changes

  • Demeanor—e.g., the resident is socializing less than normal.
  • Appetite—e.g., the resident is not interested in his or her food.
  • Sleeping—e.g., the resident falls asleep in unusual places.
  • Speech—e.g., the resident's speech is slurred.
  • Confusion or agitation—e.g., the resident is talking a lot more than usual.
  • Resident complaints of pain—e.g., the resident grimaces or winces when moving.

Slide 14

Watching for Change

  • The key is to always be watching.
  • Residents should be watched wherever they are, all the time.
  • Check in with residents often.
  • Talk with others who provide care for your residents.

Slide 15

All Members of the Interdisciplinary Team Must Watch for Changes

Physical Changes:

  • Walking.
  • Urination and bowel patterns.
  • Skin.
  • Level of weakness.
  • Falls.
  • Vital sign.

Non-Physical Changes:

  • Demeanor.
  • Appetite.
  • Sleeping.
  • Speech.
  • Confusion or agitation.
  • Resident complaints of pain.

Slide 16

What is important enough to report?

  • For about every three to five reports, one full assessment is done.
  • It is more important to report anything that might matter than to get the amount of reported information perfect.

Slide 17

How to Follow Up on the First Sign of Changes

  • Shift-to-shift comparisons.
  • Are there any changes that should be watched for or reported?
  • Early Warning tool:
    • Form that nursing assistants can use to write down what they have noticed about a resident's condition.
    • Use the tool anytime a resident has had a change.
  • SBAR tool:
    • An abbreviation that helps you to remember how to communicate change.
    • SBAR stands for Situation, Background, Assessment, Recommendation.

Slide 18

Observing and Reporting

  • Who is responsible?
  • Front-line providers are the eyes and ears of the team.
  • Part of helping the team perform best is sharing information.
  • Receptionists, occupational therapists, chaplains, volunteers, housekeeping staff, other staff members, and visitors are important observers.

Slide 19

A Safe Environment

  • Reporting changes helps keep residents as safe as possible.
  • Learning and experience help providers to keep residents safe.
  • Open communication among team members helps to keep residents safe.
  • Team members must move beyond blaming someone.
  • Those who care will speak up.

Slide 20

Summing Up:

  • Detecting changes can prevent illness from getting worse.
  • Nursing staff know the resident best.
  • Nursing staff must be alert to watching for changes.
  • The need to share observations and respond to changes is very important.
  • Staff must know what's normal for the resident so it can used for comparison when there is a change.
  • Staff must know the different changes they need to watch for.

Slide 21


  • The best way to detect a change in a nursing center resident is to get to know what is normal for that resident.
  • You can learn to be observant and to make a habit of being "tuned in" to residents.
  • Older people tend to respond less to change and may exhibit symptoms of illness that are different from those seen in younger people.
  • A safe environment supports open reporting of resident changes and does not find fault with reporters.
  • When in doubt, report a change.

Slide 22


  • Feeling that it is hard to report a change due to fear of blame is a barrier to safe care.
  • Forgetting to use reporting tools makes it harder to alert the care team to changes in a resident's condition.
  • Expecting someone else to take action when change is detected does not help residents stay safe.
  • Assuming someone else knows the resident better or knows more than you can get in the way of your desire to report what you think might be a change.
Page last reviewed October 2014
Page originally created June 2012
Internet Citation: Appendix 1-A. Suggested Slides for Module 1. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
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