SKILLED NURSING UNIT DASHBOARD CY nd Quarter Apr May June 2015 REPORT DATE: August 17, 2015

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Nelson Nelson
8 years ago
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1 GUAM MEMORIAL HOSPITAL AUTHORITY SKILLED NURSING UNIT DASHBOARD CY nd Quarter Apr May June 2015 REPORT DATE: August 17, 2015 Note: Operational Definitions can be viewed in the trending sheet. : Better than Expected Expected Needs More Work Worse Than Expected RESIDENT'S PRIVACY >75 PRESSURE ULCER MANAGEMENT FALL PREVENTION MEDICAL RECORDS (2014 CMS CITATION) PAIN MANAGEMENT ADMISSION DOCUMENTATION <75 % % % % % % 93% 99% 96% 57% 72% 68% 89% 96% 96% 98% We averaged 72% on our fall compliance rate this quarter which is an improvement from last quarter's 57%. The whole hospital is reevaluating the fall policy and even establsihed a fall team hospital wide. Problem includes the failure of the nurses to have a consistent environmental checklist and fall assesments. Page 1 of 5

DOCUMENTATION <75 % % % % % % 93% 99% 96% 57% 72% 68% 89% 96% 96% 98% We averaged 72% on our fall compliance rate this quarter which is an improvement from last quarter's 57%.

2 : Better than Expected Expected Needs More Work Worse Than Expected CALL LIGHT RESPONSE TIME AND CALL LIGHT FUNCTIONALITY - NURSING MEDICATION STORAGE EXPIRED AND RESIDENT OWN MEDICATIONS (2014 CMS CITATION) PROPER DATING AND LABELING BOWEL MOVEMENT PROTOCOL INDEPENDENT URINARY ELIMINATION INFECTION CONTROL - CROSS CONTAMINATION (WOUND CARE) CONTACT ISOLATION AND FAMILY COMPLIANCE <85 >75 <75 % 87% 80% % % % % % % % 65% 76% 96% % % 63% 69% 98% 96% 92% 98% 92% 93% % 96% 94% We are striving to satisfy our custumer needs especially on timely answering of call lights and its functionality. We are trying to pilot a program to start a partner approach among CNAs and license nurses to improve call light response time. We also improved our CNA staffing in all 3 shifts. Care plan formulation specifically making it interdisciplinary and indiviualize has been challenging for nurses despite numerous trainings given to them. With the new optimum being established we are working closely with the imed team to change the care plan formulation to make it more user friendly. Unit Supervisor has assigned a staff to conduct weekly audits on care plans especially on individualize care plans. This is a CMS citation. For better compliance, all NSS and Dakin solutions are being provided now in 500cc bottles. Consistent reminders were also given to the nurses for proper labeling and dating of solution to prevent cross contamination. Page 2 of 5

87% 80% % % % % % % % 65% 76% 96% % % 63% 69% 98% 96% 92% 98% 92% 93% % 96% 94% We are striving to satisfy our custumer needs especially on timely answering of call lights and its functionality.

3 : Better than Expected Expected Needs More Work Worse Than Expected HAND HYGIENE PATIENT OUTCOMES - PATIENT WEIGHT EMERGENCY FOOD AND WATER SUPPLY - DIETARY KITCHEN SANITATION - REVISED - REHAB SERVICES - SOCIAL SERVICES % % 88% % % % % % MOOD AND BEHAVIOR CARE PLAN % 96% % NON-PHARMACOLOGICAL COMPLIANCE - REVISED PSYCHOTROPIC DRUG USE % % 91% % 99% 78% 83% 77% 72% 78% 96% 99% 88% 85% 63% 78% The assigned person to monitor this PI had April and May months specifically targeted for dates only on the 1st and 15th without looking at the three days grace period, thus indicating it as non-compliant. Unit Supervisor personally did a review observation with the assigned person for the month of June and the compliance was %. Communication error of assigned areas of care plans for rotating staff and parttime Dietary Tech. SNU Social Workers researched the audit findings and results show that in the month of April # was admitted for only four days and # pt. expired within seven work days. For the month of May, # pt. was admitted on 05/27/15, assessment was done on 06/04/15 within 7 work days. Page 3 of 5

78% The assigned person to monitor this PI had April and May months specifically targeted for dates only on the 1st and 15th without looking at the three days grace period, thus indicating it as

4 : Better than Expected Expected Needs More Work Worse Than Expected PHARMACY REVIEW NON ACCOUNTED MEDICATION (MISSING MEDICATION) CLEANING AND DISINFECTING <10 <20 <30 >30 % ENVIRONMENTAL ROUNDS (Leak Free, Courtyard/Exterior Window Algae Free, Courtyard Animal Free, Courtyard Oder Free) % PATIENT IDENTIFIERS-- LABELING SPECIMENS FALL RATE PRESSURE ULCER INCIDENCE RATE SUICIDE PRECAUTIONS RESTRAINT USE <85 <1.5 <3.5 <5.0 >5.0 <5.0 <7.0 <10.0 >10.0 % < 10% 29% % <7.0 93% % 28% 92% 90% 88% 80% <3.5% 2% % % 1% % 1% 0% This includes all medication not renewed on time, medication that's not verified after faxing, and medication not filled in time after renewing. There is missed medication on this quarter caused by non-accounted medication. We need to work more on our system for better accountablity of prescribed medication. Page 4 of 5

RESTRAINT USE <85 <1.5 <3.5 <5.0 >5.0 <5.0 <7.0 <10.0 >10.0 % < 10% 29% % <7.0 93% % 28% 92% 90% 88% 80% <3.

5 : Better than Expected Expected Needs More Work Worse Than Expected FIRE SAFETY-R.A.C.E FIRE SAFETY DRILL % % % VOLUME INDICATORS SECURITY # OF THEFTS # OF ASSAULTS/HARRASSMENTS # OF VANDALISMS # OF DISTURBANCES/CODE 60s # OF SMOKING VIOLATORS # OF ALCOHOL CONSUMPTION VIOLATION # OF UNSECURED AREAS REPORTED # OF LOST AND FOUND # ELOPEMENT RESIDENTS VOLUME INDICATORS % % % Page 5 of 5

VANDALISMS - 0 0 0 # OF DISTURBANCES/CODE 60s 0 0 0 # OF SMOKING VIOLATORS 0 0 0 # OF ALCOHOL CONSUMPTION

Rehab and Restorative Critical Element Pathway

Rehab and Restorative Critical Element Pathway Use this pathway for a sampled resident who has had a lack of improvement in any areas of functional ability to determine if the resident received necessary rehabilitative services. Review the following