Quality Measure 10: Observing for Changes in Condition

Quality Measure 10: Basic Resident Care and Supervision – Ensuring that residents’ basic needs and preferences are sufficiently documented and addressed.

Quality Measure 10 contains fourteen Title 22 regulations.  One of these is regulation Section 87466, Observation of the Resident.  This section requires facilities—

“regularly observe residents for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs." 

It also requires- 

"such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible party, if any.”

Frequent comments from State analysts investigating these deficiencies include:

• Facility failed to observe a resident for changes in condition which resulted in harm to the resident;
• Facility failed to seek medical attention in a timely manner; and
• Facility failed to report changes to the resident’s physician and/or responsible party.

The most common circumstances surrounding these deficiencies involved incontinence care, pressure sores and falls, with State investigations demonstrating that had facility staff paid closer attention and communicated changes earlier, all parties involved would have been better off.  

While Section 87466 is only cited four times among Choose Well Members, it was cited over 50 times within the non-Choose Well group of local facilities.  All assisted living facilities can find themselves in a tough spot at times.  Caring for higher acuity residents in a non-medical setting, with non-medical staff, means some conditions may not be recognized as critical before damage is done.  Facilities are encouraged to reconsider how well they are training their staff on the importance of observation and to reevaluate how well they are supporting staff with ways to easily communicate any observed changes.

Staff Observation 

Fundamentally, RCFE staff need to understand that any observed change in a resident could be a signal that a resident’s health, safety, and quality of life may be at risk.  Even everyday interactions with residents can serve as clues for staff.  For example, if a resident is usually very vocal about their preferences and follows a set routine but suddenly is quieter and indifferent to their routine, this change may be a warning sign of more complicated (medical) issues to come (i.e., lethargy or disorientation may indicate a UTI or medication issue). 

In order to recognize these small changes as signals, staff must first have a complete understanding of what “normal” is for each resident under their care.  Facility administration should help staff establish a good sense of what baseline is for each resident by using recent assessments and family input, and by checking in with staff on resident status within the first few weeks after moving in or staff assignment.

After establishing a baseline, the staff is then ready to observe a resident for changes.  

Staff Documentation + Communication

Florida Atlantic University’s INTERACT (Interventions to Reduce Acute Care Transfers) program was created to “improve the early identification, assessment, documentation, and communication about changes in resident status."  INTERACT’s Early Warning Tool, downloadable here, is a useful tool RCFEs may wish to incorporate into their daily operations.  Though the tool was originally designed for skilled nursing facilities, the prompts are appropriate for today’s assisted living residents.  Using the acronym “STOP AND WATCH,” the tool provides a checklist of areas to monitor that may indicate a change in condition.

Having copies of this tool readily available for staff to use during their shift is an effective way to prevent changes in condition from going unnoticed and unreported. Also, rewarding staff for incorporating the tool into their caregiving practice will encourage each person to take action and not to leave it for someone else to do.

It is also important staff know they are free to share and report information openly without worrying about who might be blamed if things do go wrong.  The health and comfort of residents is everyone’s responsibility and “Observation of the Resident” is a key area that can bring your team together.

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Agency for Healthcare Research and Quality (2014). Improving Patient Safety in Long-Term Care Facilities. Available online at https://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcgdmod1.html (Accessed February 5, 2019)