Quality indicator meetings ‘de-stress’surveys

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.

Mega 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.

Dietary issues

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]).

Wound care

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).

Restraints, devices

The fourth category is restraints, followed by devices. The team reviews devices, such as wheelchairs, walkers, geriatric chairs, lap belts, lap trays, alarms, and side rails. If the patient can release the device, it is not considered a restraint. If the device could be confused with a restraint, then there must be justification for its use, such as recent falls or poor posture by the resident in a wheelchair with potential for harm. During this time we get input from floor nurses most familiar with the resident to determine if the device can be discontinued without harm to the resident. We also attempt to use the least restrictive devices. Social Services notify the families of any significant changes. During our survey, the state was only concerned about family notification of any restrictive devices. This is all care plan-based as needed (figures 4 and 5).

We continue this process to include psychotropic drugs, falls, wandering, and elopement assessments. During this meeting, we generate many orders to complete the review process and improve the quality of care for our residents. You will want to create a policy and procedure to cover this meeting to satisfy the final survey requirements. This review process can be adjusted to address any QI/QM issues that may arise out of your survey.

Darryl B. Jackson, MD, is currently the Medical Director of Delaware Valley Veterans Home, Philadelphia. He was an Assistant Medical Director at Mercy Douglass Nursing Home and Medical Director of Stephen Smith Nursing Home. He has been involved in programs at his facilities which included quality indicator meetings, wound rounds, family/care management conferences, and nursing morning report. Barbara A. Cox, RN,C, received her diploma in nursing from Helen Fuld School of Nursing, New Jersey, in 1997. She received an associate’s degree in Health Sciences from Mercer County Community College, New Jersey, in 1997, and Gerontology Certification from the American Nurses Credentialing Center in 2002. Ms. Cox has been employed with the Department of Military and Veterans Affairs as a nurse since 1998. She has been Quality Assurance Coordinator for Delaware Valley Veterans Home for the past six years and serves as the liaison for state and regulatory agencies for all facility departments. She also performs peer review for the other state veterans’ homes. Aurelio Peter Ojéda, BSN, NHA, is Administrator of the Delaware Valley Veterans Home under the umbrella of the Pennsylvania Department of Military and Veterans Affairs. He is a graduate of West Chester State University with a BSN in Nursing and has been in long-term care for 27 years. During his 27 years, he has functioned as both Director of Nursing and Nursing Home Administrator.

To send your comments to the authors and editors, e-mail jackson0509@iadvanceseniorcare.com.

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At a glance…

The Delaware Valley Veterans Home in Philadelphia uses a quality indicator meeting to address issues that may arise during state surveys, thereby alleviating stress and “surprises” during the survey process.

Long-Term Living 2009 May;58(5):31-32

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