POLICY& PROCEDURE

TOOL SBARCOMMUNICATION
Dateinitiated 1/10 Revised MedicalDirectorinitial

PURPOSE;
whenthereis a To assureoptimalcommunication betweennurseand physician significant change in a resident's condition.

PROCEDURE:
1. 2. 3. 4. 5. 6. 7. 8. in a resident. Utilize changeis identified the SBARformwhena significant Notethe onsetand history of the symptoms noted. Review medical the resident's background. concern. Complete of the resident in regards to the identified an evaluation physician. Contact the Document withthe physician. outcome of communication information on the backof the SBARform. Document any pertinent additional Resident Filethe SBARin the medical record under"lnterdisciplinary Progress Notes" section.

ICATIONTOOL E PROGRESSNOTE N URSHPHYSICIAN UN SBAR., COMM Resfdenf Room

Before callinq the phvsician: tools: D Evaluate the resident: Takevitalsigns,andotherappropriate (accucheck, pedalpulses, etc.) lungsounds, bowelsounds, etc.) nurses' notes,advanced directives, tr Reviewchart(recent falls,recentlabs,recent D Havethe information available whenyoucallthephysician. S Situation The problem/symptom beingreported is related to: AMS_Pain _Chg in Fx _Chg in intake _Labs _Resp _Gl _Chg in skincondition lf applicable: Thisstartedon-andhas:gottenbettergottenworse-stayedthesame. B Backqround primary Thisresident's diagnosis on admission: pertinent (Check information) The resident's medical or writein applicable history includes: ! Allergies: _yes _no lf yes: Recent fall(s) ! on Medication n changes recently?lf yes,state: tr lf pertinent, advanced directives: A Appearance Vitalsigns: BP_ T_ P_ R_ Accucheck_ Oxygen sat % on _room air _on oxygen@2L_on oxygen@_L via_N/C_mask n Respiratory-lf applicable:_dyspnea _congested_rales_rhonchi_pallor _cyanosis r Gl- lf applicable _nausea _vomited x_ amount_description Bowelsounds-present x_quandrants _diminshed Abdomen _distended _ sofUnontender n Changein mentalstatus,lf applicable: _forgetful_confused _agitated _lethargy Other n Pain level lf applicable: Location Scalescore_Freq uen cy:_constant _interm ittent ochangeinfunction,|fapplicab|e;-dec|ine-improvementin I Changein intake,lf applicable lf alternate nutrition recommended, residenUfamily wishes: n Ghangein hydration, lf applicable. n Ghangein skin/woundcondition: Other thingsoccurring withthe resident include: R tr
!

tr tr n

Resuesf (check whatnurseis requestino of phvsician) Visit by physician/AR NP New lab/X-ray, othertests Medication changes lV fluids Observe and report at_
RN/LPN on

Reported to Dr. by Response by received by

by _phone _fax _in person

by _phone _fax _in person at_ include: RN/LPN Newordersreceived

party Responsible on_ notified of chg in condition Documentfufther pertinentinformation on back of SBAR form.

at

by

RESTDENI fRANSFER FORM

(last,first) RESIDENT NAME

pase 1

(Name SEVf FROM: of Facility) Date

DATEOF BIRTH: AGE:

Language: rEnglish nOther:

Phone#(-)--UnitGontactpercon: SENI IO: (nameof hospital) Phone#( PHYSICIAN: )_

Currentlycoveredunder Medicare PartA in SNF no ves

Residentis n Short-term n Lonq-term CONTACT PERSON: Name
a HCS o HCP o POA n DPOA n Guardian a Other Phone #(_)

Dr.
Phone *(-)--.

Notified of transfer Aware of Diagnosis

Jes _no Jfes _no

Resident has: (Aftached a DNR _yes _no) n Livinq will (Attached ves no) o Facesheet o Currentorderc n Bed hold policy o Labs/X-rays

The following are attached:

REASOru FOR TRA/VSFER: (Be specific)

Route of transport

Ambulance

Ambulance service called_

WC van _Car

DIAGIVOSES:

V/S= BP_

T_P_R_Accucheck_

02 sat

% on _RA_O2 at_L
Site_ n C-Diff as of_ date n Seizure a Skin breakdown others self

Precautions: o MRSA as of_ n VRE as of_ date date

DEVICES/SPECI AL TREATM ENTS : n lV/PIGC/Mid-line r Foleycatheter n Ostomy o Pacemaker n lnternaldefibrillator n TPN Other: IMMUNIATIONS:
Influenza Givenon_ Pneumococcal Givenon_ Other Given on Refusedon Refusedon_ Refused on_

R/SKALERIS:
n None n Aspiration a Restraints n Falls o Elopement n Harmfulto

E FREQ UENCI ES: SPECIAL TREATMENTS

(lncludedialysis,chemotherapy, radiation,hospice,etc. here)

RES'DENT TRANSFERFORM
USUALMENTAL SIATUS:
n Alert o Forgetful n Disoriented n Can a Cannot follow instructions

page2 DIET: n Assistneeded n Trouble swallowing n Specialconsistency_

(Ihickened pureed, liquids, crush meds) o Tubefeeding Timeof lastmeal

USUAL FUN CTION AL SIA IUS; Ambulates ADLs: r independently l=indep A= Assist D=depen r Withassist _Bathing _Dressing n Withdevice _Toilet _Transfer r Non-ambulatory WBS _full _partial _non
IMPAIRMENTS:

CONTINENCE: lncontinent n Bowel a Bladder Currently on retraining tr yes tr no Lastbowelmovement on

n Speech n Vision Other:

o Hearing n Sensation

DISABILITIES: n Amputation u Paralysis n Contractures

SKIN/WOUNDCARE: Highriskfor pressure ulcerdevelopmenttr yes tr no Woundprogress noteattached n yes n no Reddened areas/excoriations: Site (Site,stage, Pressure ulcers: size)

Treatment:

PAlN:Usua|sca|e(1-10)-Site-Presentsca|e(1-10)-Site Specifics, if applicable:

(if applicable); USUALBEHAVORS EXHIBITED ANDINTERVENTIONS

SOCI AL SERY'CE INFORM ATION: Socialworker Phone # Reason for originaladmission to SNF plan u Return Discharge home n LTC n Bedhold Resident o is n is notadjusted to illness Family n is n is notsupportive Resident n is a is notselfmotivated Formcompleted by: Reoortcalledto Signature
RN/LPN

By

RN/LPN

POLICY& PROCEDURE

OF ACUTECARE QI TOOLFORREVIEW TRANSFERS

Dateinitiated1/10 Revised Medical Director initial

PURPOSE.
To assuremedical necessity when residents are transferred to the hospital.

PROCEDURE:
1. Upona resident's transfer to the hospital a Ql TOOLFORREVIEW OF ACUTECARETMNSFERSwill be completed by the facility's Director of (DON). Nurses 2. All areaswill be completed. 3. The DONwill determine if the transfer was avoidable and why the determination was reached. 4. The DONwill try to identify any actionsthe facility can implement to improve management of resident changes in condition. 5. The DONwillfax eachcompleted of Clinical Services Ql Toolto the Director at the management company officewithina weekof the transfer. 6. The DONwillcomplete a briefsummary of the Ql Toolfindings for each monthfor review at eachQuality Assurance meeting.

QI TOOL FORREVIEWOF ACUTE CARE TRANSFERS

FaCility: (Gircte) Broward Ptantation Springtree Tamarac Pinecrest OceanView

Residentname

Admission date

Residentstatus at time of transfer n Long-term nShort-term o Medicaid n Privatepay Paystatus: o Medicare n HMO,typeAdmissiondiagnosis: Datetransferred to hospital Transfer -was-was not via 911 Physicianorderingtransfer: Dr. BP T P_R_PULSE OX-T}

What promptedtransferto hospital?

(circle)

Was residentadmitted? Yes/No lf so, admitting Dx status at the time of admissionreEardinqthe reasonfor discharqe: (For Whatwas the residentns at thetime of admission) whatwas the hemaglobin dueto a low hemaglobin, is transferred if resident example,

What interventionsdid the facility employ in an attemptto preventthe residentfrom havingto return to the hospital?Gheckwhat appliesor write in below. Be

Gouldthis transfer have beenavoided? _Yes -Possibly -No Give reasonsbelow: suchas and/ormanagement, withearlieridentification to prevenUanticipate Therewereopportunities E
n
D

tr tr

careand services: necessary to provide The facility was unable withfurtherinformation/discussion. if provided in the facility may havekeptthe resident The physi-cian calls. had returned if the physician maynot havebeentransferred The resident but services provided and care further The facilitycouldhave physician insisted on transfer on transfer family insisted or -resident

as a result of this transfer? to preventre-hospitalizations What actions are you implementing DateSignature DON