The Path to Excellence: How One Facility Received and Maintained a CMS 5 Star Rating

Transcription

1 The Path to Excellence: How One Facility Received and Maintained a CMS 5 Star Rating South Mountain Healthcare and Rehabilitation Center 2385 Springfield Avenue Vauxhall, NJ Author: Antonio Onday, BSN, RN, BC, FACDONA Author Affiliation: Director of Nursing Introduction South Mountain Healthcare and Rehabilitation Center, located in Vauxhall, New Jersey, has received a CMS 5 Star rating for the last 2 years. Achieving this level of excellence in quality care comes from a combination of management s commitment to support quality programs, staffing, and capital needs for the facility, and the clinical team s initiative and passion for quality care. SMHC s staff has made their facility the place that everyone wants their loved one to go to, including the physicians, staff, and regulatory authorities who visit there. Former patients who find themselves in need of rehabilitative care later on, invariably return to South Mountain. South Mountain Healthcare and Rehabilitation Center consists of 195 licensed beds, with 55 designated sub-acute beds. These separate sub-acute units provide rehabilitative care and therapy for a broad range of needs, including post cardiac surgery care, orthopedic surgery care, motor vehicle trauma, and wound care. The remaining beds are for long-term care, respite and hospice services. SMHC maintains a virtually constant 95%-98% occupancy, a very high percentage for the industry. For the past 4 out of 6 years, South Mountain has been recognized as deficiency-free on State surveys, a rare distinction. The facility also received a CMS 5 Star rating for the last 2 years, placing it in the top 10% of nursing homes nationwide. This ranking assesses health inspections, quality measure ratings and overall staffing ratings. Additionally, the facility maintains RN staffing around the clock in all sub-acute units, which far exceeds the CMS 1 RN/24 hour requirement, giving SMHC a consistent 5 Star RN staffing rating over the last 2 years. Here are some of the measures that were taken to achieve this level of excellence. Education & Training Due to the increasingly early discharge of acute care patients from hospitals, providing care for the post-acute patient population has become increasingly challenging. Continuous education is necessary in order to effectively incorporate the constant technological advances in medicine. Of course, this can only be effective if there is significant retention of qualified staff. Care for today s gerontologic patient requires a high level of staff competency and extensive training, which should include all levels of staff. SMHC stays ahead South Mountain Healthcare and Rehabilitation Center Lobby of the curve to meet this challenge by not only performing core competency training, but also in providing demonstrations of necessary skills, inviting speakers into the facility, which may either be academic or industry partners who give specific training on devices and procedures such as complex monitoring systems, IV pumps, pressure ulcer prevention and wound care treatments. Staffing Retention Currently about 50% of all long-term care/ rehabilitation directors of nursing leave facilities within one year of being hired, leaving facilities in a constant state of transition. In contrast the SMHC management team fosters an environment of longevity, empowering the staff to make appropriate decisions and to be accountable for such decisions. The administration recognizes the staff on a regular basis, creating a culture of learning and respect, and resulting in a very high rate of staff retention. SMHC staffing retention averages 5-7 years for RN/ LPN staff, years for the management team, and up to 20 years for certified nursing assistants. The staffing ratio at South Mountain consistently exceeds CMS requirements, and allows the facility to accept patients with more challenging medical needs.

2 Technology Part of the needed technology was the 2007 purchase of the CareAssist beds manufactured by Hill-Rom, in Batesville, Indiana. The state-of-the-art pressure redistributing mattress has played an important role in maintaining a very low rate of nosocomial pressure ulcers. Moreover, the staff report that the beds make life easier for everybody. As one unit manager explains: Before we had the beds, in order to weigh a patient we needed 2-3 staff members, depending on the size and condition of the patient, move the scales into the room, stand the resident up, and then let go of them to get an appropriate weight. In some cases this procedure caused falls and became a safety concern. Now, we simply zero the bed before the resident enters the room, and then we just push a button for the required weekly weights. Implementation of a falls prevention protocol that includes using the bed exit alarm on the Care Assist beds to notify caregivers that patients were attempting to exit the bed resulted in a zero rate of bed egress falls in the sub acute unit during The other key advantage that the CareAssist bed provides is the ability to position patients to allow for ergonomic ease of staff to perform dressing changes and other procedures, which reduces the risk for staff injury. This significant capital investment has been very worthwhile, as it has been an important factor in patient satisfaction. It is also perceived by physicians, discharge planners, and social workers, as an integral component in providing a quality environment. Patient response to the beds has been very positive. In a recent survey of 30 patients admitted to the Post Acute area of SMCH, 94% of patients said that the bed contributed directly to the overall quality care that they received, and 100% reported that the bed would influence their decision to return for rehabilitation services in the future. The beds were acknowledged to be comfortable and the residents are pleased with the aesthetic appearance of the bed. Overall, they have exceeded the patients expectations for their care. Quality Measures Hill-Rom CareAssist Bed taking functionality into the extended care environment SMHC has implemented constant surveillance and documentation processes for the following quality measures: nosocomial pressure ulcers, weight loss, falls, medical errors, and infection control (see attached form). If any of the above events occur, a special root cause analysis form is completed by the unit manager. These forms are reviewed by the Director of Nursing who then discusses the event with the staff. Additionally, by the end of each month reports are presented to the management team and the unit staff and analyzed. Recommendations are made as to what measures are needed to rectify the issue, and they are acted upon expeditiously. The administration and owners of SMHC review these monthly reports, and are very supportive of implementing needed changes. This approach has led to significant reductions in almost all areas of quality focus. Quality Improvement Process Changes A significant effort has been made to reduce falls in SMHC. Part of the falls reduction program is the Smiley Program, where a Smiley sticker is placed on the door of patients identified as a fall risk. Another part of the fall reduction program has been the utilization of the CareAssist bed exit alarms. The alarms are especially useful for patients who were identified as at-risk for falls by scoring > 10 on the falls risk assessment, or patients who have had prior history of falls with injury at home. As part of the overall falls reduction protocol the exit alarms on the Care Assist beds were set to alarm when patients were attempting to exit the bed. Compliance with the protocol, including the ability for staff to respond quickly to the bed exit alarm, was credited with reducing patient falls during bed egress to zero during Additionally, the pressure redistributing mattress has contributed to the very low rate of nosocomial pressure ulcers. Sub-Acute Unit Data Bedside Falls (Ingress) Bedside Falls (Egress) 10 0 Nosocomial Pressure Ulcers 0 1 Commitment and Leadership A primary reason for SMHC receiving the CMS 5 Star Quality rating is the amount of foresight invested in preventing negative events, as well as the thoroughness of documented follow through when such events do occur. The above root cause analysis accurately documents what happened, why it likely happened, and what is being done to prevent its recurrence. The analysis is readily available for surveyors review. Summary A 5-Star rating does not just happen. It is the result of years of hard work and a commitment to quality and excellence from owners and staff alike. Specific goals of perfection must be set, with a clearly defined plan to reach those goals. Upon attaining those goals, there must be a consistent operational effort to maintain them, with constant vigilance in root cause analysis of events, and appropriate education and training of staff. Constant and periodic improvement efforts are crucial in ensuring that the overall excellence in quality care that has been achieved does not erode. We are faced with the task of providing care to an increasingly more challenging population of patients. In many facilities, the nursing team has limited support from their management or owners, which inevitably leads to a downward spiral of events. In order to properly care for our patients we must have adequate and consistent staffing; compliance with established processes and procedures; continuous improvement efforts; and dependable, high-quality equipment. This will allow providers of longterm care and rehabilitation to make each facility a place where we would be comfortable taking one of our own family members for care. 8/26/10

3 South Mountain Healthcare Root Cause Analysis of Nosocomial Pressure Ulcer Done By Name of Resident Unit Rm Date Discovered Stage Site / Location of Ulcer Instructions: A) Describe or give a brief summary on how the resident sustained or developed the new facility acquired decubitus ulcer. Cite both intrinsic and external factor including medical diagnosis that may have contributed to its development. Factors such as neglect of duty e.g. Left drenched with urine and feces, failure to reposition, failure to turn and/or provide positioning devices, etc, must be included in the summary. B) Responsible Employee/s who committed the neglect

4 C) Action plans / Prevention Strategies Including Discipline / Education / Training of Employees: 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ D) Documentation Done Timely On: (Date) 1. Nursing Progress Notes 2. Care Plan 3. Weekly Progress Sheet E) Comments Reviewed by Date Suggestions / Comments:

5 South Mountain Rehabilitation Center Fall Inspection Resident Name Unit Room Date of Fall Time am/pm 1) Time resident last seen prior to fall am/pm by whom condition / position when last seen. 2) Has resident had previous episodes of orthostatic hypertension? Yes No If yes, explain 3) Medication Related Dose Frequency Time last given 4) Was resident incontinent when found? Yes No If yes, when was the patient last toileted/changed? 5) Environment? Please write an explanation of resident surroundings: 6) If out of bed was appropriate, well fitting footwear on? Yes No Was floor free of puddles / spills? Yes No Was cane, wheelchair, walker in reach? Yes No 7) Was the resident agitated prior to fall? Yes No If Yes, how was this handled and how effective was this? 8) Does the resident have a behavior plan? Yes No Was it being followed? Yes No Explain: 9) Did the resident have any complaints of pain or discomfort on the hour prior to the fall? Yes No If Yes, how was it handled

6 10) Could the resident offer an explanation of what happened? Yes No If Yes, explain: 11) What are the identified factors that may contribute to further falls? 12) Resident referred to the following for follow up: Physical Therapy Occupational Therapy Speech therapy Activities Psych Eye consult Hearing evaluation MD for Medical workup CNA Name: Signature of Charge Nurse: Date Completed: