Long-Term Care Survey Alert

Quality indicators may seem like a burden, but smart facilities recognize them as blessings in disguise, experts say.

While QIs provide surveyors a ready-made report card on a nursing facility's restorative nursing program, your facility also can use its QI profile to monitoritsrestorativecareeffortsandlowerthosered flags before the next survey.

This is especially important in heading off G-level (actual harm) citations for a resident who has experienced an avoidable decline in functional status that could have been prevented by simple restorative measures.

According to B.J.Collard, a restorative nurse specialist and principal of CTSInc., in Westminster, CO,the top five quality indicators facilities should track to flag potential problems with their restorative care systems are:

QI #8 - prevalence of bowel or bladder incontinence;

QI #9 - prevalence of occasional or frequent incontinence without a toileting plan;

QI #16 - prevalence of bedfast residents;

QI #17 - incidence of decline in late loss activities of daily living;

QI #18 - incidence of decline in range of motion.

"In addition, QI #2, prevalence of falls, and QI #24, prevalence of pressure ulcers, can also reflect restorative care," says Collard.

Debra Ohl, principal of Ohl & Associates Long Term Care Consultants in Cleveland, notes that about 20 of the 24 QIs are in some way tied to restorative care, "although ADLs and incontinence, including catheter use, are big ones."

Ohl also advises nursing facilities to look at psychoactive medication use to see if these drugs are improving or diminishing the resident's functional status and his or her ability to be involved in restorative nursing programs.

Say your facility ranked at the 75th percentile on QI #17, decline in late-loss ADLs, and you want to know if there's a restorative care issue behind the high score. Collard suggests facility staff first pull a sample from the facility page of the QI profile that lists the individual residents. If the MDS has been scored correctly, determine if the resident had a restorative need based on the scoring at Section G for bed mobility, transfer, eating and toilet use.

If so, did the facility identify the need, address that need on the care plan, implement a restorative nursing program and document the program provided? "If all of these steps were not taken, a care issue is present," Collard explains.

If it's a care issue and the resident experienced an avoidable decline or complication of immobility as a result, the facility could be setting itself up for a G-level deficiency, says Annette Fleishell, vice president of clinical services with JoAnne Wilson's Gerontological Nursing Ventures in Laurel, MD. On the other hand, if the individuals in the sample have a deteriorating condition with an expected decline, then the restorative program is probably not at fault.

"If an organization specializes in provision of care to residents with end-stage multiple sclerosis, as an example, and the decline happened no matter what staff did to prevent it, the high QI percentage is due to the facility's case mix," notes Collard.

Even if that's the case, however, the facility staff should address the decline in the care plan and medical record documentation, indicating that it is expected. "You prove the decline was unavoidable through your documentation of your assessment and interventions,etc.,"says Fleishell

Residents with Alzheimer's disease, for example, usually respond well to toileting programs until they cross a certain point in the disease progression.

Fleishell also advises facilities to make sure to include the diagnoses on Section I of the MDS that indicate conditions resulting in an unavoidable decline.

Some residents may have declined due to an unavoidable temporary situation, such as a bout of pneumonia, which was addressed by the treatment plan. Again, the key is to document that the facility is aware of the temporary decline and has intervened.

Using QIs to track restorative care is a proactive approach.Yet facilities can take that a step further by zeroing in on declines in ADLs or range of motion, as examples, before they trigger a QI. "When you complete the MDS and a resident has had a decline in one ADL, that's the time to figure out why and intervene," says Fleishell.