MDS Alert

Alert charting for ADLs can help staff spring into action.

Is your assessment and reporting system set up to catch the first sign of an ADL decline before it takes the resident -- and your survey record -- down with it?
 
If not, MDS staff may not catch a resident's loss of function until they do the quarterly MDS. Then surveyors will sweep in and oftentimes find the CNAs actually documented subtle signs of the decline months ago, notes Rena Shephard, MHA, RN, FACDONA, president of RRS Healthcare Consulting in San Diego and chair of the American Association of Nurse Assessment Coordinators. The net result: F309 and other tags -- not to mention poor quality indicators/measures.

Try this: Alert charting may be the ticket to keeping residents' in tip-top shape with their ADLs, according to Shephard, who presented on the topic at the fall 2003 AANAC conference in Las Vegas. "If someone on the interdisciplinary team suspects that a person's illness or signs of decline will cause more long-term problems, then place that resident on 'alert charting' for continuing monitoring," Shephard advises.

Using alert charting for ADLs is somewhat of a novel concept in many facilities, Shephard tells Eli. "Nurses automatically use that [type of] charting when patients develop a fever or some neurological changes, as examples," she says.

"In those kinds of situations, the nurses are right on top of the problem with a care plan and continuous monitoring and charting every shift for 72 hours, and if the person isn't stable after that, then ongoing until the person is stable again," Shephard notes. She believes the same process can be used to monitor residents specifically for loss of ability to perform their ADLs.

Implement a Training and Reporting System

For alert charting to work, CNAs must know how to detect and report subtle changes in the resident's ability to transfer or toilet, etc. But in Shephard's experience, usually CNAs are noticing the resident's decline. "They know the person required a two-person rather than a one-person assist to toilet, or more help getting dressed," Shephard says. "But they don't understand the importance of reporting it." Thus, training is the first step to catching subtle, but significant ADL changes.

"The nursing aide on a night shift should know to tell the charge nurse at report that she had to provide more assistance in transferring a resident than his usual baseline requirement for support," Shephard advises. The charge nurse then writes that information in the 24-hour report book. At that point, the charge nurse should do two things:

1. Follow up with an assessment and care planning;

2. Tell the MDS nurse if the resident is in an assessment window for the MDS, in order to capture that information for RUGs or the OBRA-required care plan.

If deemed necessary, the resident then goes on "alert charting" where staff assesses his functional status at agreed-upon intervals. The resident stays on alert charting until someone in charge determines that the resident's ADL status is no longer a problem, Shephard advises.

In some facilities, anyone with a concern about a resident can put the resident's chart in the "hot rack" for more intensive assessment and monitoring, but only the DON can pull it back out, reports Beth Alford, RN, principal of Professional Liability Insurance Services in Belton, MO.

Watch Out for These 3 Red Flags

Identify a list of potential triggers for possible ADL decline. Top of the list: Delirium or acute changes in cognitive status/sensorium. In fact, Shephard advises putting residents who have such signs on alert charting.

"Delirium places the resident at serious risk of permanent cognitive deficits and ADL decline," Shephard notes. "Delirium can impact ADL status because as soon as someone becomes more confused, they may have more problems remembering what it is they are supposed to be doing with their ADLs or their attention span will be shorter."

Assessment tip: Any time you see an acute change in mental status, use the delirium RAP, which leads you through suggested possible causes or contributing factors to delirium. "That way the facility doesn't have to reinvent the wheel," Shephard notes.

In addition to delirium, these conditions can be an ADL decline waiting to happen: 

1.  An acute illness, such as the flu. When stricken, the resident will stay in bed more and won't eat well. "And staff will correctly identify that the person doesn't want to do much because he's sick," Shephard notes. "But by the time the person's acute illness is better, he may have lost some ability to do ADLs on his own."

The goal in such a case is to have a plan to spring into action during the recovery phase to help the resident regain his functional capacity. "You want to make sure staff is giving resident all the opportunities to become independent again or as independent as he was before he got the flu," Shephard says.

2.  A fall or symptom that raises the resident's fear level.  A resident can become fearful of walking or transferring on her own, even if she wasn't hurt by a fall, says Clare Hendrick, RN, CRNP, vice president of education and clinical development with Health Essentials in San Clemente, CA.  Or residents may become immobilized by frightening symptoms, such as heart palpitations or dizzy spells, which they may not have reported to the staff.

"Thus, staff needs to assess exactly what the person is afraid of in order to design interventions to promote ADL functioning," Hendrick advises.

3.  A new medication that impacts the resident's ability or willingness to do ADLs independently. "Someone's ADLs might be off because he is having side effects from a medication, such as dizziness from a new blood pressure medication or tiredness," Hendrick reports. Some medications affect appetite, which can cause the resident to eat less and have less energy. "In that case, you may need a medication consultation, or the resident may need more support during the time she acclimates to the medication," Hendrick says.

Integrate Restorative Nursing

Don't turn the ADL ball solely over to the restorative nursing program when combating potential functional decline, Shephard advises. She has seen facilities have some success with restorative nursing protocols where the team moves in quickly with key triggers, such as the aftermath of an acute febrile illness. "But if the restorative team is ambulating the person a couple of times a day and doing range of motion a couple of times, that's not enough to help the resident regain his mobility or to prevent contractures," she cautions.

While it's important for residents who have a true need for restorative care to have that kind of focused attention, the nursing staff at the bedside must support that effort, Shephard adds. "And that includes giving the resident time to do for himself rather than going ahead and 'doing for' the resident," she cautions.

"Even restorative nurses fall into that trap where they get busy and might provide more assistance than needed to help get the resident out of bed and walking down the hall," Shephard counsels.

Yet the "sit to stand function" that develops strength in the hips and lower back is so important for residents to maintain or regain their ability to ambulate, Shephard observes. "And the ability to ambulate is such a quality of life issue" for anyone, she emphasizes.

Know When to Call Rehab

If the nursing effort doesn't turn things around for the resident, the rehab therapist should evaluate the person to see what's going on ... and determine if the person is a candidate for rehabilitation therapy, suggests Pauline Watts, PT, cofounder of Encompass Education in Palm Harbor, FL. 

Combat this survey misperception: "Unfortunately, a lot of surveyors [believe] that a resident should not have had a decline because therapy should have been working with him, even though the person is really at a maintenance level," Watts adds. "But that shows the surveyor doesn't understand the medical necessity Medicare guidelines."