MDS Alert

Take a proactive tack with your hospitals.

No person is an island, and neither is a nursing facility - a truism that you can use in working with hospitals to head off PPS and survey woes.
 
Guardian Angels Care Center in Elk River, MN has some lessons to share in that regard. "We have good relationships with our two primary hospitals ... and have had some success in educating them about how the PPS works," explains DON Lynn Gerard, RN, C, BSN. For example, Guardian Angels has dialogued with the hospitals about issues such as what antibiotics they select for patients prior to discharge and when they can convert patients on Lovenox to Coumadin prior to transferring them to the SNF, Gerard says.
 
"It's an educational process to let the hospital know how the more expensive drugs come out of the SNF's per diem and that there are equally effective, lower cost drugs available," Gerard says.
 
Education can also help hospital staff understand why it's so critical for the SNF to know if a resident had IV fluids or IV meds during the hospital stay - and the duration of those treatments. Even then, Gerard sometimes receives admission paperwork from the hospital showing a patient didn't have an IV for a condition that normally requires IV meds or fluids. In such a case, she calls to clarify. "If you don't make those attempts or don't know the clinical requirements for the patient's diagnosis, then the facility will not capture that information on the MDS," Gerard cautions.
 
Gerard also requests copies of residents' IV meds and IV flow sheets to check the numbers of ccs of fluid. "Even though 'keep vein open' IVs count on the MDS, it's good to have that information and documentation in case a surveyors has a question about the resident's condition," Gerard reports.
 
To capture information about the three-day qualifying hospital stay for SNF Part A benefits, Guardian Angels asks the hospital to put the admission time on the face sheet along with the day of admission. "We also validate that information with the hospital on all admissions by calling the hospital," Gerard explains.

Keep an Eye on Pressure Ulcers
 
You should monitor how your residents fare during hospitalizations - a tactic that can head off survey issues if residents return with pressure ulcers or other hospital-acquired conditions. Here's how it works at Guardian Angels: Each time a resident is admitted from the SNF to the hospital, the SNF staff sends along a transfer form outlining the resident's condition at the time of discharge from the facility. And when the resident returns to the facility, the admitting staff on the first shift performs a body audit and documents any skin problems (tears, pressure ulcers, bruising, etc.) as hospital-acquired.
 
"The hospitals we work with do a good job with skin care," Gerard emphasizes. But when employed by another nursing facility, Gerard worked with a hospital where residents developed pressure ulcers when cared for by a particular unit in the hospital. "We followed up with the medical director of the hospital" about the problem, she says, even though it's a difficult thing to do.
 
"There's a presumption on the part of acute-care providers that their care is the premiere health service and they don't like to hear that a nursing home might do a better job in some areas," Gerard notes. "So it is disheartening for them to hear that their staff is allowing someone who came in with clear skin to return to a nursing facility with a stage 2, 3 or 4 ulcer."

Do Your Homework
 
If your SNF plans on confronting a hospital about residents who develop pressure ulcers during inpatient stays, do a root cause analysis up front to pinpoint what's going on. "Present specific cases and documentation, and identify which hospital units are involved," suggests Darla Watson, RN, vice president of beneficiary support for Mariner Health Care in Atlanta. "For example, the SNF may be able to show data indicating that the incidents occur repeatedly when their residents are admitted to the med-surg unit, but not the orthopedic floor."
 
"The hospital DON has the right to know if there is a quality of care issue involving nursing on one of the floors or units," Watson adds. "But it would be prudent for the facilities to approach the hospital in a politically sensitive manner, as the hospital is the SNF's referral source," she advises.