Chapter 22 Quality Assurance and Performance Improvement BOX 22.4 Illustrating Quality Assurance and Performance Improvement in Action


The scenario below illustrates how a QAA committee might develop a plan of correction in response to deficien- cies identified during an annual survey. The example shows how facilities often react to regulatory noncompli- ance with a “Band-Aid” approach. The activities described are representative of the types of plans of corrections that are often submitted to survey agencies and accepted. It addresses the immediate problem and then takes steps to prevent recurrence of the problem.


Scenario 1:


Issue: Your nursing home, Whistling Pines, received deficiencies during its annual survey because residents had unexplained weight loss, and weights and food intake were not accurately and consistently documented.


What Whistling Pines did: The QA committee developed a plan of correction, which contained the following components: Reweighing all residents and updating the weight records for the affected residents and in- servicing the nursing department on obtaining and documenting weights and intake. They stated they would conduct three monthly audits of weight and intake records, with results reported to the QA committee.


This plan of correction was accepted by the State Survey Agency.


The next case study shows a facility with effective QAPI systems in place to identify issues proactively, before trends become serious problems. A nursing home chooses a limited number of PIP projects in “high-risk, high-volume, problem-prone” areas.


Scenario 2:


Issue: During the monthly QAPI meeting at Whistling Pines, staff discovered a trend of unexplained weigit loss among several residents over the last two months. During the discussion, a representative from dining services noted that there had been an increase in the amount of food left on plates, as well as an increase in the amount of supplements being ordered. Although other issues and opportunities for improvement were identified at the meeting, the QAPI Steering Committee decided to launch a Performance Improvement Project (PIP) on the weight loss trend because unexplained weight loss posed a high-risk problem for residents.


What Whistling Pines did: The QAPI Steering Committee chartered a PIP team composed of a CNA, charge nurse, social worker, dietary worker, registered dietitian, and nurse practitioner. The team studied the issue and then performed a root cause analysis to help direct a plan of action. The RCA revealed several underlying fac- tors, which included the following:


●


No process existed for identifying and addressing risks for weight loss, such as dental condition, diagnosis, or use of appetite-suppressing medications.


● No system existed to ensure resident preferences were honored.


● Staff lacked an understanding of how to document food intake percentages. ● Residents reported the food was not appetizing.


Based on the identified underlying causes, the PIP team recommended the following interventions: ●


●


Development of a protocol for identifying residents at risk for weight loss to be done on admission and with each care plan. This protocol included a review of medications (appetite suppressants), new diagno- ses, and resident assessments, including dental issues.


Development of standing orders for residents identified as “at risk” for weight loss. These would include biweekly weights, referral to the attending physician and dietitian for assessment, and documentation of meal percentages.


●


Development of a new program for CNAs to be “Food Plan Leads” for at-risk residents. The program would include identification of food preferences and accurate documentation of meals—laminated badge cards with pictures of meal percentages were distributed to all CNAs.


●


Revision of the menu to focus on favorite foods, adding finger foods and increasing choices outside of mealtimes.


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