Quality improvement in long term care This paper develops the plan (preventing falls) to improve the quality of care to the residents of Althea Woodland Nursing Home, located in silver Spring, MD, using Deficiency Report and the Quality Indicators as the instruments of achieving this goal. This work will depict the following matters in the Woodland Nursing Home: its characteristics, resident demographics, quality measures and will be based on its Deficiency Report and Quality Indicators. Sources of Data The guide that is used for data references in this work employs publicly available data. It has been collected as part of the state and federal procedures for overseeing nursing home conformity with regulations and sent to the Centers for Medicare and Medicaid Services (CMS), the federal agency that monitors long-term care in nursing homes (Maryland Nursing Home Evaluation Guide 2005). Characteristics: This institution, which is Medicare and Medicaid certified and which exists for profit purposes, is a considerably small facility with only 50 beds (state average being 125). It provides such clinical services as Dementia/Alzheimer care, rehabilitation care, catheter care, central IV therapy, total parenteral nutrition, with hospice available and respite care offered. 56 % of this nursing home’s patients are males and 44% – females; average age is 75, with most residents being under 65 (31%), and 42% suffering from severe Dementia. To continue, the plan for long term care improvement in this nursing home aims to improve the current situation with falls at this facility (most residents with the above disease and impaired mobility characteristics have higher risk of fall then the patients at other facilities). The following Quality Measure or Quality Indicators endorsed by CMS are used by Woodland Nursing Home: Data Source: Maryland Nursing Home Performance Evaluation Guide (2005). Timeframe: 01/2001 through 12/2005 = top 20% of all facilities (smaller number of poorly managed events) = bottom 10% of all facilities (greater number of poorly managed events) = all other cases N/A = Indicator could not be calculated because too few patients met its criteria. Activities of daily living weakening (Chronic Care) Inadequate Pain Supervision (Chronic Care) High-risk patients with pressure ulcers (Chronic Care) Low-risk patients with pressure ulcers (Chronic Care) Low-risk patients who suffer the loss of control of their bowel or bladder (Chronic Care) Patients who have a catheter in the bladder (Chronic Care) Patients who stay in bed most of the time (Chronic Care) Residents with alterations in their mobility (Chronic Care) Those with a urinary tract infection (Chronic Care) Those patients with worsening of a depressed mood (Chronic Care) Dominance of daily physical restraint use (Chronic Care) Failure to improve/supervise delirium symptoms (Chronic Care) Inadequate Pain Supervision (Chronic Care) Following is the Deficiency Report of the Woodland Nursing Home, which provides basis for the mentioned above long-term care improvement plan designed to prevent or at least number of falls in this nursing home’s residents. Deficiency Report Data Source: Maryland Nursing Home Performance Evaluation Guide (2005). Date of Inspection Type of Inspection (s=Survey; c=Complaint) Number of Deficiencies Substandard Quality of Care All Other Deficiencies July/7/2005 S 5 0 Result: in the non-occurrence of any citations, it was determined that the Althea Woodland Nursing Home was in considerable conformity with regulations. Falls Prevention/Reduction Plan (the Domain Quality Indicators are listed in Appendix A) Preventing Falls and Improving Falls Nursing Care In order to effectively manage and prevent falls, a complete history and assessment of the immediate underlying causes and related risk factors should be measured.

Next, the nursing staff should determine the exact circumstances that led to any fall and conduct a physical examination immediately after the fall occurred. Such procedure must include taking blood pressure and pulse (supine and standing at one and three minutes). In order to effectively manage falls in long-ter care patients, the following measures should be adopted: 1. Nurses are to look also for any signs of dehydration; loss of visual sharpness; loss of hearing; whispers such as aortic stenosis; and carotid bruits and upstroke. 2. Organize a stool hemocult test and a thorough neurological test, including an examination of strength, reflexes, coordination and sensation. 3. The nursing staff must also conduct a direct observation of performance. (It is imperative to ask a person to perform the exact actions they were doing when they fell). 4. Perform the extremely simple Stand-Up-and-Walk test, where the nurse asks the patient to stand from a straight-back chair. 5. Then the nurse should do a personalized Romberg test, where the patient stands with eyes open and then shuts his or her eyes followed by a sternal nudge or drag at the waist. After that the nurse should ask the person to walk 10 feet, make a 360-degree turn, go back to the chair and sit down. There are many methods of scoring this test, but in reality it is more practical to employ the test qualitatively. 6. finally, laboratory appraisal should include routine tests and, depending on the person’s presentation, cardiac enzymes, ambulatory cardiac testing, echocardiogram, carotid sinus pressure application, neuroimaging researches and electroencephalogram, or vision, hearing and vestibular examination. The person who fell should be referred to physical and occupational therapy for rehabilitative measures to be applied, including transfer, balance and gait teaching; strength and range-of-motion workout, and habituation workout for vestibular troubles; also training in the safe performance of everyday chores. The nursing staff must design a personalized workout program, consisting of weight-bearing exercises to prevent osteoporosis and hip damages and non-weight-bearing training, such as Tai Chi, which have been proven to reduce falls. In nursing homes, the patient's room can be placed closer to the nurses' station, and the number of nurses can be increased to improve the quality of care provided. Environmental dangers should be examined and eliminated. Nurses are to ensure that beds’ height and side rails are fixed properly, and that there’s proper light, grab bars, firmly positioned mats and handrails. As in most branches of nursing, falls prevention and management is being subjected to rigorous evaluation for evidence of efficacy and accuracy. While there is a strong imperative in medicine to use evidence-based and quantitative research as a guide to practice it should be acknowledged that qualitative research designs provide a rich description of the relationship between nurses’ beliefs about falls and suffering and actual falls management. Similarly, insights into patient responses to falls and suffering uncovered by qualitative studies may help to provide the means to abolish many barriers to effective falls control. In order that elderly with falls problems become beneficiaries of optimum preventing strategies there is a need for multi-disciplinary collaboration between clinicians and other health care providers (nurses in our case). The foundation of this collaboration is education. Clinicians, patients, administrators and politicians need access to the new concepts of fall and its management in order to start realizing this goal. No amount of empirical information about pain can help the nurse whose fundamental concepts and attitudes towards falls are outmoded.

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Since nurses are involved in patient care around the clock, spending more time in contact with patients than other team members, it is a serious situation indeed if the nurse lacks the appropriate knowledge, skills and attitudes to assess frailty in elderly. If a comprehensive picture of the patient's response to falls and interventions is to be transmitted to doctors and nursing colleagues, regular assessment of falls’ reasons and treatment outcomes need to be documented as meticulously as other clinical data such as blood pressure, pulse and temperature. In the light of what is known about neural plasticity in reponse to noxious stimulation, it makes good sense to take steps to prevent or reduce pain occurring from falls. Nurses are well placed to influence patients’ perceptions of frailty. They can reduce anxiety by listening to patients’ stories about previous encounters with falls and how they coped or how they did not cope. Explaining to surgical patients what to expect and how they will be helped is a prerequisite for reducing anxiety. Treating the operation as ‘just routine’ is likely to have the opposite effect to what is intended by such utterances. An operation or even a test, no matter how minor, is not routine to the person about to experience it. Falls’ reasons assessment should begin at admission, establishing a pain history; questions related to previous painful episodes, their management and outcomes are as necessary as those questions used to elicit past medical history and fitness for anaesthesia. TABLE 1 Common Reasons of Falls in the Althea Woodland Nursing Home’s Patients ________________________________________ Accident, environmental danger, fall from bed Gait trouble, balance disorders or frailty, pain because of arthritis Vertigo Drugs or alcohol Severe illness Confusion and cognitive weakening Postural hypotension Visual sickness Central nervous system disorder, syncope, drop attacks, epilepsy TABLE 2 Drugs That May Add to the Risk of Falling ________________________________________ Tranquilizer -hypnotic and anxiolytic drugs (particularly long-acting benzodiazepines) Tricyclic antidepressant Main tranquilizers (phenothiazines and butyrophenones) Antihypertensive medicine Cardiac drugs Corticosteroids Nonsteroidal medicine preventing inflammatory cases Anticholinergic medicine Hypoglycemic agents Any drugs that are likely to affect balance Assessment of the Elderly Patient Who Falls Testing and screening at Althea Woodland Nursing Home Elderly patients in this nursing home with determined danger factors for falling should be questioned about falls on a regular basis. Precise questionnaire is essential because of the fears many elderly persons have about being placed into a specialized ward fro treatment. Thus, these patients are not likely to give falling as a chief medical problem. It should be notes that a single fall is not necessarily a sign of a large problem and an increased risk for more falls. The fall may simply be an unrepeated event. Yet, frequent falls, defined as more than two falls in a six-month period, should be examined for treatable causes. An immediate study is required for falls that create injuries or are associated with a new severe illness, loss of consciousness, fever or abnormal blood pressure. History A thorough history is necessary to conclude on the mechanism of falling, specific risk factors for falls, impairments that add to falls and the proper diagnostic work-up. Many patients at Althea Woodland Nursing Home consider a fall to by "just tripping," but the nurse must determine if the fall happened because of an environmental obstacle or another leading factor.

The nurse should observe the activity the patient is engaged in just before and at the time of the accident, particularly if the activity involved a positional change. The location of the fall should be determined. It is also important to be familiar with whether anyone saw the fall and whether the patient received any injuries. Risk Factor Assessment The risk of receiving an injury at Althea Woodland Nursing Home from a fall depends on the individual patient’s vulnerability and environmental dangers. The frequency of falling is connected to the combined effect of multiple disorders superimposed on age-related alterations. The risk factors accountable for a fall can be intrinsic (i.e., age-related physiologic alterations, diseases and medications) or extrinsic (i.e., environmental dangers). It is essential to keep in mind that a single fall may have multiple projections, and frequent falls may each have a different etiology. Osteoporosis is directly related to injuries and falls. Therefore is should be studies as well. The osteoporosis functional disability questionnaire was developed as a specific instrument to measure disability in several domains: feelings of adequacy, comfort, mood, activities of daily living, instrumental activities of daily living, and social activities. Self-evaluation of impairment (on a Likert scale 1-5 indicating frequency and/or severity of problems) provides information for designing and planning self-care and supportive activities. Motivation and need for participation at Althea Woodland Nursing Home in therapeutic regimens and exercise programs should be evaluated by the following indications: Please indicate in degrees of 1 (good) to 5 (poor) your estimation of your general health aside from your osteoporosis —Please indicate in degrees of 1 (no difficulty) to 5 (very difficult) any problems meeting your financial commitments in the following areas. Pain — General health — Appearance — Interferes with social activities — Interferes with work — Other — Mark in degrees of 1 (least) through 5 (most) the organizations or groups of importance to you that you are hindered from enjoying because of your osteoporosis. Recreational — Fraternal — Civic/political — Other — Indicate by numbers 1 (least) through 5 (most) the intensity/ frequency of feelings you have experienced in the past week. I was bothered by things that usually don't bother me. — I did not feel like eating; my appetite was poor. — I was unable to shake off the blues even with help from family and friends. — I felt I was just as well off as other people. — I had trouble keeping my mind on what I was doing. — I felt depressed. — I felt as if everything I did was an effort. — I felt hopeful about the future. — I thought my life had been a failure. — I felt fearful. — My sleep was restless. — I was happy. — I talked less than usual. — I felt lonely. — People were unfriendly. — I enjoyed life. — I had crying spells. — I felt sad. — I felt that people disliked me. — I could not get going. — Indicate by numbers 1 (unable) through 5 (independent) your ability to accomplish the following activities without assistance. Get in and out of bed — Use the toilet — Bathe yourself — Dress yourself — Put on your shoes — Cut your toenails — Modified from Helmes E, Hodsman A, Lazowski D, Bhardwaj A, Crilly R, Nichol P, Drost D, Vanderburgh L, Pederson L. (1995). “A questionnaire to evaluate disability in osteoporotic patients with vertebral compression fractures”, J Gerontol 50A(2):M91-M98. This structure should be applied at Althea Woodland Nursing Home. Assessing falls structure is provided below. Source: Capezuti E. (1996).

“Falls”. In Lavizzo-Mourey R.J., Forciea M.A., eds. Geriatric secrets. Philadelphia: Hanley & Belfus, pp. 110-5. In conclusion, Deficiency Reports Key trend in health and social services in many developed countries is the increasing recognition of the relevance and importance of the consumer’s voice in determining how well services are meeting needs. In the residential aged care sphere in the US, one of the most notable developments in this regard could be the introduction of outcome standards. These standards can used as a basis for external monitoring and assessment of residential aged care facilities by the federal government. While this monitoring and assessment process will always take residents’ views into account, it may not do so in any systematic way, relying largely on ad hoc, often impromptu “interviews” with a small number of residents during visits by standards-monitoring teams to different aged care homes. APPENDIX A DOMAIN QUALITY INDICATOR Accidents 1. Incidence of new fractures 2. Prevalence of falls Behavioral/Emotional Patterns 3. Prevalence of behavioral symptoms affecting others (verbally abusive, physically abusive, or socially inappropriate/disruptive behavior) 4. Prevalence of symptoms of depression (sad mood plus at least 2 of the following: resident made negative statements, agitation or withdrawal, wakes with unpleasant mood, suicidal or has recurrent thoughts of death, weight loss) 5. Prevalence of symptoms of depression and no antidepressant therapy Clinical management 6. Prevalence of residents using 9 or more different medications Cognitive patterns 7. Incidence of cognitive impairment Elimination/incontinence 8. Prevalence of bladder or bowel incontinence 9. Prevalence of occasional bladder or bowel incontinence without a toileting plan 10. Prevalence of indwelling catheters 11. Prevalence of fecal impaction Infection control 12. Prevalence of urinary tract infections Nutrition/eating 13. Prevalence of weight loss 14. Prevalence of tube feeding 15. Prevalence of dehydration Physical functioning 16. Prevalence of bedfast residents 17. Incidence of decline in late loss of ADLs 18. Prevalence of decline in range of motion Psychotropic drug use 19. Prevalence of antipsychotic use in the absence of psychotic and related conditions 20. Prevalence of antianxiety/hypnotic use 21 Prevalence of hypnotic use more than two times in the last week Quality of life 22. Prevalence of daily physical restraints 23. Prevalence of little or no activity Skin care 24. Prevalence of stage 1-4 pressure ulcers Source: Manard, B. (2002). Nursing home quality indicators: Their uses and limitations. Washington, D.C.: AARP: http://assets.aarp.org/rgcenter/health/2002_16_homes.pdf

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