Long-Term Care Survey Alert

Quality Of Care:

Short Stays May Signal Your Care Has Gone Astray

Published on Tue Jun 28, 2005

Get on top of this trend before it leads down a path to F tags.

There's short and sweet - and there's short and potentially dangerous, which includes brief nursing home stays that could reflect a patient care or safety shortfall.

A high percentage of residents with stays under seven days can be a red flag, cautions Cecelia Strow, RN, MPS, CNHA, FACHCA, CEO of MyZiva.com in Lake Success, NY. "Short stays can reflect discord between the admissions department and case management, poor care - or the staff may misunderstand the facility's mission," says Strow.

The facility should be able to identify the reason for a short length of stay and especially a pattern of short stays, agrees Diane Atchinson, RN, MSN, principal of DPA Associates in Kansas City, MO.

For example, is the facility admitting residents it can't care for properly due to lack of skilled nursing training? If so, patients may require rehospitalization or die within a few days of admission to the nursing facility, says Strow.

Example of a training shortfall: A facility admits a patient receiving partial parental nutrition with a central venous catheter, postulates Jacqueline Vance, RN, director of clinical affairs for the American Medical Directors Association.

"Yet the staff hasn't been trained to maintain and monitor a central line or on the complexities of parenteral nutrition," Vance says. "So the nursing assistant accidentally dislodges the central line when repositioning the resident - and the nursing staff does not notice the signs and symptoms of central line infiltration. Or the staff fail to monitor the patient's labs properly, and the patient develops a fluid and electrolyte imbalance."

Solutions: Work with the medical director to identify admissions policies so you don't admit residents you can't care for, suggested Vance and AMDA executive director Lorraine Tarnove in a presentation at the most recent American Association of Homes & Services for the Aging annual conference in Nashville, TN.

Give Staffing, Resident Monitoring a Check-up

A facility with an unexplained pattern of short stays may not be monitoring common medical conditions that, left unchecked, result in hospitalization. For example, you have to find ways to staff to your resident acuity and the skill sets of RNs, which change shift-to-shift or over time, observes Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego. Also consider using a 24-hour reporting and alert charting system to identify residents requiring more intensive nursing service for conditions that could require hospitalization, if left unmonitored, suggests Shephard. Examples might include residents with fever, serious pain, signs of delirium, potential dehydration, unstable vital signs or fluid/electrolyte imbalance.

Consider implementing a primary nursing model where the CNAs care for and get to know the same residents over time. That way, CNAs can be taught to detect early signs of delirium in a resident with some level of pre-existing dementia, says Shephard. "Delirium is often the first sign of infection or serious acute illness," she notes.

Other questions that should appear on your quality assurance radar screen include:

Is the facility transferring residents to the hospital who could have been cared for in the facility? For example, many residents can be treated for pneumonia in nursing homes, which also prevents the transfer trauma and negative outcomes of hospitalization (pressure ulcers, delirium, etc.), says David Mehr, MD, MS, associate professor with the Department of Family and Community Medicine at the University of Missouri at Columbia (for details, see the next story).

Does the facility care for a high percentage of residents who push the envelope to get back home after intensive rehab or nursing care? That could be a re-hospitalization or even a lawsuit waiting to happen if you discharge a medically unstable resident without appropriate follow-up care.

Solution: "Before the resident leaves ... educate the person/family about the potential risks and outcomes" of an early discharge, advises Reta Underwood, a survey consultant in Buckner, KY. "Also let the resident/family know what to do to ensure his care and meet his medical and nursing needs," Underwood adds. "Document the teaching in the medical record."

Preempt This Legal, Safety Issue

Elder abuse laws come into play in situations where the facility staff suspect the person's primary caregiver, such as a spouse, may be too incapacitated to care for the resident safely at home, says Underwood

"If you send the resident home with that person, you are endangering the resident potentially," cautions Underwood.

In such cases, identify and meet with another family person who agrees to be responsible for the resident's transition to community care, Underwood advises. And validate that the home health or other ancillary providers are in place before the resident goes home.