AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention

Facilitator Training—Additional Exercises (continued)

Risk Change Report Information Exercises

Objective: Facilitators will understand the process to prioritize residents on the Risk Change Report for use in On‐Time process improvement strategies.

Exercise #1: Risk Criteria and Rules

Please choose the best answer to the questions.

  1. Residents who display on the High-Risk Nutrition Report also will display X in the Wt Loss ≥5% in ≤30 Days column on the Risk Change Report.
    1. True
    2. False
  2. Worsening Pressure Ulcer information is captured from weekly wound assessment documentation.
    1. True
    2. False
  3. If wound assessments are not being completed in the health IT system used at the facility, then Worsening Ulcer and New Ulcer columns will always be blank.
    1. True
    2. False
  4. Resident behavior information may be captured from nursing assistant daily documentation or nurse documentation.
    1. True
    2. False
  5. The Risk Change Report displays residents with changes in documentation of urinary incontinence and behaviors from the prior report week.
    1. True
    2. False

Answers

  1. False
  2. True
  3. True
  4. True
  5. True

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Exercise #2: Prioritize Residents at Highest Risk

Using the sample Risk Change Report below, select up to five residents you would consider highest priority.

Sample 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    



Answer: All of the residents on this report appear to be at high risk, but residents 2, 3, 4, 5, and 7 appear to be highest priority.

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Exercise #3: Report Data

  1. How many residents have documented changes from the previous report week?
  2. How many residents have high nutritional risk? Should these residents also display on the High-Risk Nutrition Report?
  3. How many residents have an increase in urinary incontinence from the previous week?
  4. How many residents have changes in behaviors from the previous week?
  5. How many residents have worsening ulcer, as documented on nurse wound assessment?
  6. How many residents have a new ulcer, as documented on nurse wound assessment?
  7. How many residents appear to have incomplete CNA documentation in at least one area?

Answers:

  1. 6
  2. 2 (#3 and #5). Yes.
  3. 2 (#2 and #3)
  4. 3
  5. 1 (#7)
  6. 1 (#5)
  7. 2 (#2 and #4)

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Exercise #4: Report Calculations

Please choose the best answer to the questions about report calculations.

  1. Weight Loss ≥5% in ≤30 Days uses the same calculation as Nutrition Risk Report.
    1. True
    2. False
  2. Urinary Incontinence Increase is determined in the following ways (choose all that apply):
    1. The number of shifts of urinary incontinence increased by 3 or more from prior week
    2. The number of shifts of urinary incontinence increased by 12 from prior week
    3. The sum of urinary incontinence episodes increased by 3 or more from the prior week sum of urinary incontinence episodes
    4. The sum of urinary incontinence episodes increased by 12 or more from the prior week sum of urinary incontinence episodes
    5. None of the above
  3. If a nursing assistant documented 4 unique behaviors for a resident who did not have any behaviors documented the prior week, what would display in the Behaviors ≥3 column for that resident?
    1. 4*
    2. 4
    3. A dash (-)
    4. Cell would be blank
    5. None of the above
  4. An asterisk (*) displays next to the number of behaviors when:
    1. The resident is a new admission
    2. The resident has not had behaviors documented previously
    3. The behaviors required medication intervention
    4. One or more behaviors for the report week were different from behaviors documented the prior week
    5. None of the above
  5. What would you expect to see on the Risk Change Report for a resident who triggered for High-Risk Nutrition but has incomplete bladder and behavior documentation for the report week? (choose all that apply)
    1. X will display under Decreased Meal Intake + Weight Loss
    2. Dash (-) will display under Urinary Incontinence Increase & Behaviors ≥3
    3. Urinary Incontinence Increase & Behaviors ≥3 will be blank
    4. The resident will not display on the Risk Change Report when any report documentation is incomplete
    5. None of the above

Answers:

  1. b
  2. a, d
  3. a
  4. d
  5. a, b

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Risk Change Report Implementation Exercises

Objective: Facilitators will understand how to coach teams on implementation of report use. Sample report results will be used to discuss the various ways to interpret report results. Facilitators will be prepared to respond to a variety of questions from clinical teams implementing the Risk Change Report for the first time.

Exercise #5: Implementation: Key Points

Please choose the best answer to questions about report implementation.

  1. The Risk Change Report may be used by social services to monitor changes in resident behaviors.
    1. True
    2. False
  2. Restorative program teams may use the Risk Change Report to monitor changes in resident urinary incontinence.
    1. True
    2. False
  3. The Risk Change Report offers an at-a-glance snapshot of residents who may have experienced changes in nutrition, urinary incontinence, behaviors, and ulcer status from the prior report week.
    1. True
    2. False
  4. A strong nursing and social services collaboration results in effective meetings.
    1. True
    2. False
  5. The following are examples of forums for using the Risk Change Report: (choose all that apply)
    1. Nursing assistant shift report
    2. Care plan meetings
    3. Risk meetings
    4. Nurse/social worker huddle
    5. Nurse/ restorative huddle
    6. Dietitian/wound nurse huddle
    7. None of the above
    8. All of the above

Answers:

  1. a
  2. a
  3. a
  4. a
  5. h

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Exercise #6: Coaching Teams Through Use of Report Information

Scenario: The sample Risk Change Report below was generated for a single nursing unit. The team you are facilitating is assembled for a routine meeting.

  1. What questions will you ask the team about how they are using the report?
  2. What questions will you ask your nurse/social worker team about the Risk Change Report information? Restorative nurse? Wound nurse?
  3. What questions will you ask your team about interventions for residents? Followup with other staff members?
  4. What questions would you consider asking the team about facility processes?
Sample Risk Change Report
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 0001     X X                
Resident 2 0002   X   X     X X       X
Resident 3 0003 X     X X       3      
Resident 4 0004     X     X            
Resident 5 0005 X   X               X  
Resident 6 0006     X                  
Resident 7 0007                 4 X    



Answers:

  1. When are you using this report? At which meetings? Who attends? How frequently do you meet?
  2. Nurse/social worker: Are you using this report to monitor behaviors? Is this information helpful? How do you use the information?
    Restorative nurse: Are the residents with an increase in incontinence and with ADL decline involved in the restorative program?
    Wound nurse: Is the report helpful in tracking residents with new or worsening pressure ulcers? Would you take this report to wound rounds or wound review meetings?
  3. Nurse/social worker: Have the care plans been updated for the residents with changes in behaviors? Is a psych consult or med review needed? Have the nursing assistants been trained or retrained on how to manage those new behaviors?
    Restorative nurse: Are the care plans up to date for the residents on restorative with ADL decline? Do the nursing assistants know the current plans for helping to improve or prevent further decline with these residents? Is a urinary incontinence management plan in place?
    Wound nurse: Will you use this information to check if treatment changes need to be made?
  4. Was a root cause analysis done for the new pressure ulcer noted on the report?

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Page last reviewed April 2016
Page originally created March 2013
Internet Citation: AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/addexercises2.html