Sun Management Services Inc

Senior Housing Management

SOP# N131 Revision 0 Effective Date: 01/29/08 Prepared By: DKJ Approved By: CAM

Title: Examples of Resident Observation Evaluation Reporting and Response

Resident Observation and Evaluation Reports (ROER’s) are to be made to identify and determine those who experience either a short-term change of condition or a significant change of condition, and the facility’s response with actions, interventions, monitoring and documentation as appropriate to meet the resident’s needs. For resident’s who experience a significant change of conditions, the facility responds with evaluation, appropriate medical care, referral to the facility nurse, assessment, appropriate follow-up care, interventions, monitoring and documentation as appropriate to meet the resident’s needs.

Below are a few examples of “changes in condition”:

Level of Functioning such as ADLs (activities of daily living) 1. A resident was able to transfer independently from a chair to a standing position and then walk, but now requires the assistance of staff and a walker to do the same activities. 2. A resident who could hear and see loses the ability or a resident with cognitive loss establishes a pattern of not using their hearing aids or glasses.

Behaviors 1. Changes in the intensity and frequency such that: Behaviors that were easily altered by minimal intervention now require more frequent and intensive or complex interventions. 2. Development of new behaviors. 3. Behaviors may include pacing, crying out, trying to leave the facility, being verbally or physically abusive, etc.

Continence Pattern 1. A resident who was continent of bowel or bladder becomes incontinent most or all of the time.

Weight Regardless of cause, 1. Change in pattern in eating 2. Loss of appetite, or pattern of refusing to eat 3. Difficulty swallowing or chewing

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Mood 1. A resident’s usual mood, changes. They may appear sad or anxious and don’t respond to staff interventions that have been effective in the past.

Level of Consciousness 1. The resident may be difficult to arouse, or appears less alert or to have difficulty communicating.

Health Status May include by not limited to: 1. Unmanaged high or low blood sugar levels (blood sugar levels that exceed the parameters defined by the physician) * medical emergency 911 2. *Broken bone 3. *Stroke 4. *Heart attack 5. Major surgery (*complications) (* This is likely to result in sudden change in health status and way of life.)

Uncontrolled Pain 1. Resident experiencing continuous or intermittent pain which is not being controlled by their current treatment plan and/or interventions. 2. Pain could have been gradually increasing over time or an acute change following an injury, surgery, or development of an infection of pressure ulcer.

Skin Condition Pressure Ulcer 1) Injury to the skin from constant pressure due to staying in one position without moving. 2) Blood flow is reduced and eventually causes cell death, skin breakdown and developments of an open wound. 3) Pressure ulcer usually occur over bony prominences (such as tail bone and heals) and are staged to classify the degree of tissue damage.

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Response to “Significant” change of condition and monitoring: A significant change of condition is a major deviation from most recent evaluation that may affect functioning or health. Not expected to be a short term condition. A significant change of condition has the potential for significant risk to the resident. 1. Determine actions and/or interventions required: This would be initiated by management or the facility RN using the Wellness Center Assessment & Communication Form (SOP #N213) and as “follow-up” on the ROER (SOP #N130). 2. Communicate information to each shift for monitoring: This would be initiated by management or the facility RN using the Caregiver Evaluation Progress Notes (SOP #N215) or the Caregiver III Evaluation Progress Notes (SOP #N214). 3. Document staff instructions in resident record: This may be done by changes to the resident’s service plan which would be updated by management or the facility RN. 4. At least weekly documentation of resident’s progress until resolved: Caregivers, Management, and the Facility RN would document updates on the Progress Notes mentioned above.

Response to “Short-Term” change of condition: A short term change of condition is expected to resolve or reverse with minimal intervention, or an established predictable, cyclical pattern associated with diagnosed condition (e.g., Parkinson’s, MS, etc.) 1. Evaluate the resident: Evaluation of the resident would be recorded by management on the ROER. 2. Refer for appropriate medical care: This may include, but is not limited to, the resident’s physician, home health agency, urgent care, caseworker, etc. 3. Refer to the facility RN for assessment: Management will refer to the facility RN whenever an RN assessment is necessary. When available the RN assessment will be completed in person, but there may be occasion where a verbal assessment be completed via phone. A verbal assessment from the RN will be followed up in person, as soon as available. 4. Evaluation and service plan update: 5. Follow-up care: Instructions will be provided to staff based on the evaluation (and assessment if applicable) through physician notes, on-site provider documentation, and the progress notes mentioned above. 6. Interventions, monitoring and documentation: Short term instructions will be provided to staff using the progress notes mentioned above, and also through changes in the resident’s evaluation and service plan, which would result in changes to the resident’s ADL’s.