Among skilled nursing facilities (SNFs) in 2015, potentially avoidable rehospitalization rates for the first 30 days of a stay averaged 20.2% for the lowest-performing quartile of facilities, compared with 8.4% for the highest-performing quartile, according to the Medicare Payment Advisory Commission’s 2018 Report to the Congress (pp. 115–116). The first 8–24 hours after admission are key to preventing rehospitalizations. Shelly Acus, RN, DNS-CT, director of nursing services (DNS) for Maple Knoll Village in Ohio, and Kristin Bernard Breese, BSN, RN, CPC, RAC-MT, owner of Post-Acute Clinical Advisors LLC in North Granby, Connecticut, suggest the following best practices to prepare your facility staff and your new residents for the best outcomes.
1. Thoroughly assess the resident throughout the first 8–24 hours. “Head-to-toe assessments upon admission should include a close look at vitals, lung sounds, skin integrity, fall risk, and a close look for edema,” says Acus. “If possible, an RN should be charged with admission assessments, as RNs are better trained to gather information and make a clinical decision.” She suggests that after the initial assessment, vital signs in particular be checked frequently.
2. Ensure assessments are consistent. Breese stresses the importance of the consistency of assessments throughout the first 8–24 hours. “If I look at the nurse and ask, ‘Did you do an assessment?’ and the nurse says, ‘What do you mean by an assessment?’ that is a problem. You need to make sure that everyone is doing the same assessment so that you will notice a change.” She suggests requiring the Situation Background Assessment Recommendation (SBAR) tool to ensure that assessments upon and after admission are consistent.
3. Know the primary causes for rehospitalization and allow them to guide you in your intake procedures. “Falls, infection as a result of a catheter or IV, and a change in respiratory status are common causes for rehospitalization to keep in mind,” says Acus. She suggests that providers screen new residents carefully for risks associated with these causes.
4. Get information with as much detail as possible from the transferring acute facility. Written reports often don’t include all of the information that nurse-to-nurse conversation offers. Acus suggests having a form ready with a checklist of relevant questions that you don’t want your nurses to miss when they talk with the discharging nurse. For example, if the resident is noted as having a fall risk, why? Did the resident have a fall while in the hospital? Was there a specific intervention in place? “In a nurse-to-nurse conversation, it might be revealed that an alarm was in place because the resident didn’t like to use the call light but instead frequently tried to get up unassisted. This might reveal that the resident has a more impulsive temperament, which could guide decisions such as to place the resident in a room near the nurses’ station or upgrade to a specialty low mattress,” suggests Acus.
Acus also suggests giving attention to whether an indwelling Foley catheter was in place during the resident’s stay in the acute setting. “If the acute facility pulls a catheter right before discharge, it presents an increased risk of UTI. Anytime you have a foreign device, it opens up a portal for germs, presenting a greater risk of infection.”
5. Understand that you may not get every detail in advance of admission. “While the ideal would be to learn everything about a resident in advance, it’s not typical,” says Breese. “If you don’t know everything about the resident that you need, there’s the possibility that your facility won’t be prepared to care for the resident and that the resident will end up having to go back to the acute setting instead of admitting. You want to make sure that you learn all imperative details, to avoid having to send the resident back.” After admission, the opportunities to learn about the resident greatly increase.
6. Don’t leave information for another department to figure out. Nursing shouldn’t leave questions unanswered for another department to figure out. Breese stresses that “as nurses, we need to make sure we have a complete picture of the resident. This includes the complete picture of their mental and physical state, as well as their cultural and religious preferences and trauma history.” Thinking or assuming that therapy or social services should or will collect information that is absent in the chart is counterproductive to good resident outcomes.
7. Ask the family for details about the resident. Medication-administration missteps—typically either a missed medication or a new medication that causes an interaction—are often why residents fail, says Breese. Acus agrees: “It’s possible that when the resident was admitted to the hospital, they may have been taken off of a drug they had been using for years. When the resident enters the SNF, it’s imperative to review the medication list thoroughly to make sure all medications were transferred accordingly.”
According to Breese, “In addition to asking the resident’s previous pharmacies to send a list of medications, I ask the family to bring in every pill bottle that the resident has at home. This gives us lots of information.” Acus also suggests gathering as much information as possible from a newly admitted resident’s family and/or significant other. “Talking with people that are closest to the resident gives you an idea of the resident’s normal patterns. It also tells you if it’s out of the ordinary that a resident hasn’t been sleeping or other changes that could alter his behavior or mood.”
8. As you learn the true status of the resident, get your ducks in a row. Often residents will share vital information after admission that they didn’t previously share in the acute setting because they didn’t think it was important, says Breese. For example, a resident once shared after admission to the SNF that she had fallen nearly every day at home before being admitted to the hospital, but she hadn’t shared this with the hospital because she didn’t think it was relevant. Breese suggests that “as you learn more about the resident’s needs, adapt and adjust their care plan accordingly.”
9. Talk to residents and their families about cultural and religious expectations. “Sometimes what a new resident expects at the skilled nursing facility and what we think they should expect are very different. As a result, the resident isn’t comfortable and becomes overwhelmed by anxiety, often wanting to go back to the hospital,” explains Breese. She recalls a newly admitted male Muslim resident who for a week had been getting undressed by female CNAs, which often led to his becoming aggressive. As it turned out, his aggression was the result of discomfort: in his culture, it wasn’t appropriate for an unrelated female to see him naked, but he didn’t articulate this and his anxiety increased as it continued to happen, increasing his aggression.
“It’s important to ask the family: are there any cultural preferences that your loved one needs to have followed?” says Breese. “You should also ask: has your loved one ever had a significant trauma?” These are things the hospital may not ask or have a record of, but for the SNF staff, having a better understanding of the resident’s needs and establishing expectations in advance is necessary.
10. Put the information into a care plan that the whole team can follow ASAP. Not only is it required to have a care plan written within 48 hours, it is crucial to initiate appropriate care planning after the initial assessment. “The initial care plan doesn’t have to be all-inclusive, but it should give direction to team members as far as how to take care of the new resident and how to mitigate risks,” says Acus. Even before the care plan is approved, pertinent care plan interventions should be available to team members via electronic medical records or other means. Reviews and revisions can always be made.
Breese agrees: Even though the care plan doesn’t need to be finished for 48 hours, the plan should be in progress and in review as soon as possible. “If the care plan is created overnight, does the day shift look at it before they deliver care?” Breese further suggests that nurse managers review the care plan and educate the floor nurses. “What if the night-shift nurse learns that a resident hasn’t taken his medications in two weeks? The day-shift nurse doing the med pass should know that. Everyone decides in their head what’s important to pass on in a verbal report, so it is important for nurse managers to review the full written report and make sure all pertinent information is passed along.”
11. Use paper checklists! Electronic medical records have very helpful features, but they can also be limiting, according to Breese. “Often, there isn’t a quick space to populate with cultural preferences, for example,” she says. Paper checklists can be a helpful tool for nursing staff to collect information that will help the resident to succeed.
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