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Improving  Outcomes  Through  Risk  Mi6ga6on

Bruce Majors Dir. of Safety & Loss Prevention Emeritus Senior Living

Ray Miller, MSOSH Dir. of Risk and Safety Direct Supply, Inc.


What  Has  Changed  In  YOUR  World?   Self-­‐repor6ng  requirements  

Background  and  fingerprint  check  

  1.4  m-­‐ Skilled  Residents   1.0  m+  AL  Residents  

Assisted  Living  vs.  Hospice  

Staff  Training   Culture  

E-­‐payment  and  E-­‐records  

What   asn’t   changed?       You   S2ll  Chare   About   PEOPLE.  

Acuity  

Medica6ons  

Threat  of  li6ga6on   Family  and  Resident  Expecta6ons  

Media-­‐Rela6ons  

Regula6ons  –  in 2012, apprx. osha  

120,000 state AL-related bills submitted nation-wide; no such number available for Skilled


Objec6ves  

At the conclusion of this session, you’ll walk out of here with: 1.  A few thoughts on how mitigate “risk” by using Resident and Staff Engagement 2.  Some thoughts on empowerment to better achieve “Q2” 3.  Renewed determinations and a few valuable insights


Disclaimer  

     The  materials,  comments  and  other  informa6on  contained  in   this  presenta6on  are  intended  to  provide  general  informa6on   but  not  advice  about  certain  regula6ons  and  ini6a6ves.        This  informa6on  is  not  and  not  intended  as  legal  or  other  advice   and  each  situa6on  may  vary  depending  on  the  par6cular  facts   and  circumstances.      You  should  not  act  upon  this  informa6on  without  first   consul6ng  with  qualified  legal  counsel.     Thank you.  


David O. McKay -- 1968

“‘Words do not convey meanings; they call them forth.’ I speak out of the context of my experience, and you listen out of the context of yours, and that is why communication is difficult.” Just because we say something, does not guarantee that you know what we mean – please speak up.

© 2009-10 Direct Supply, Inc., all rights reserved


Agenda 1.  2.  3.  4.  5.  6. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A  


What is “Risk Mitigation” –  Risk Management: Identification, assessment, and prioritization of risks as well as identifying how to prevent and mitigate the effects of those risks –  Risk Mitigation: Efforts to reduce the probability, frequency and severity of an incident Does this then imply that all risk can be eliminated if “WE” have identified it and reduced the chances of it occurring? NO – Accidents will happen!


This suggest that sometimes it is not the event that occurs, but how it is managed...

Chesley Burnett "Sully" Sullenberger ‌ ditched USA Flight 1549 in the Hudson River back in January 15, 2009 and saved 155 people.


Part of our goal today is to discuss;

–  What “risks” are “over the horizon”?

–  Are there some that we are perhaps we are ignoring?


Agenda 1.  2.  3.  4.  5.  6. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A  


12  


Agenda 1.  2.  3.  4.  5.  6. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A  


FDA Dimensional Guidelines: Entrapment Zones


Zone 1

Recommended  Space:   Less  than  4¾”    

CAUTION:  Openings  in  the  rail  


Zone 2

Recommended  Space:   Less  than  4¾”    

CAUTION:  gap  between  the   bo\om  of  rail  and  ma\ress  


Zone 3

Recommended  Space:   Less  than  4¾”    

CAUTION:  Ma\ress  width  


Zone 4

Recommended  Space:    Less  than  23/8”    

CAUTION:  at  the  end  of  the  rail    


FYI: Zones 5 through 7 do not have specific dimensional guidance

Zone Zone 55

Zone Zone 66

Zone Zone 77


Zone 5

Zone  5  –  two  sets  of  rails/side  


Zone 6

Zone  6  -­‐-­‐  rail  and  side  of  head   or  foot  board  


Zone 7

Zone  6  -­‐-­‐  between  end  of   ma\ress  and  head/footboard       CAUTION:  76”  and  80”  look   similar  


FDA Guidelines (http://www.directsupply.com/resources/) 1.  Dimensional 2.  Clinical a. Resident and environmental assessment programs b. Treatment programs/care plans 3.  Safety Products 4.  Mitigation a.  Modifying unsafe beds b.  Process to assess beds c.  Corrective action products 5.  Implementation


Agenda 1.  2.  3.  4.  5.  6. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A  


Elopement Mr. Smith was here this morning – now we can’t find him! There are not too many other situations that can have such a negative effect on the whole community!

Two questions from a “Risk” & “Safety” viewpoint: 1.  Can we ensure families that we prevent elopements? 2.  Are we truly managing these events?


Definition of “Ensure”: To “make certain” or “sure of” Is this the same as saying, “We will prevent all resident falls.” Can we or should we promise either of these? What is the starting point in our striving to prevent “Elopements” and lower our “Risk”?

The Admission Process


Suggestions for Admissions 1.  Are we evaluating the resident’s cognitive level or ability upon admission? 2.  Are we explaining the “risk factors” involved with elopement? 3.  Appropriate placement? AL or Memory Care?

Are we meeting the needs of our resident?


Prevention Considerations •  Use of the sign-in book •  Change of medications / Changes in Condition What about the “Physical Plant” •  Door alarms •  Patio furniture / Fencing •  Electronic monitoring devices


Managing Elopement

Initial checks should be completed first to determine if a resident is “Missing”. These include: •  •  •  • 

Checking sign in / sign out book Bus transportation log Favorite places the resident like to go Checking with other employees and residents. Who saw the resident last?

If it is determined the resident is “Missing”, then what are your search procedures? What is your “Plan” to manage this?


Managing Elopement “The Plan” should include: •  What areas are going to be searched and by who •  How the search will be expanded “outside” the community •  Designate the responsible party who will do notifications (Family, Physician, etc..)

•  When to call in additional help and who is going to make this decision, (Law Enforcement, etc..) •  Documenting search procedures and notifications •  Who will be responsible for handling the “Media”?

Besides the above, suggest the most important activity we can do is to:


EDUCATE AND PRACTICE to prepare if an “Elopement” would occur! 1.  Make “Elopement” procedures part of employee orientation, 2.  Practice the procedures - At least annually! 3.  Incorporate these drills into the community in-service and schedule.


Agenda 1.  2.  3.  4.  5. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a.  Mentoring (Listening, Developing, Engaging, Harvesting) b.  Hand-off Pneumonics c.  Daily Contracting d.  DRILLS 6.  Q&A  


VISIT  &  LISTEN  

EDUCATE  &  DEVELOP  

ENGAGE  &  HARVEST  

MENTORING  


VISIT  ↔  LISTEN  

EDUCATE  ↔  DEVELOP  

ENGAGE  ↔  HARVEST  

1.  Rela6onship  ques6ons   2.  Round  with  them   3.  What  went  well?   4.   What  didn’t  go  well?     1.      Do  you  have  the  tools,   training   and  resources  to  do   MENTORING   your  job?   2.    What  is  working  well?     1.  How  can  we  “fix”  “this”?   2.  Who  is  doing  a  good  job?   3.  What  systems  can  work   be\er?  HOW?  


SIDEBAR: “Clues and Ques” Or “Itchy Vigilance” Which  of  these  would  YOU  make  note  of?    

–  Less  visible  in  the  community   –  Check  for  changes  in  meds   –  Recent  trip  to  the  physician   –  Off  pa\erns  or  habits  

1.  Why?  

–  Change  in  rou6nes  

2.  When?  

–  Posture  change   –  “Color”  change   –  New  cough   –  Pain  

3.  Learned?   4.  Teachable?   5.  How?  


Agenda 1.  2.  3.  4.  5. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a.  Mentoring (Listening, Developing, Engaging, Harvesting) b.  Hand-off Pneumonics c.  Daily Contracting d.  DRILLS 6.  Q&A  


Mnemonics  

“Every  Good  Boy  Does  Fine”   +   “FACE”   “ROYGBIV”    


“Hand-­‐off”  Mnemonics     1.  AIDET

9.  Just Go NUTS

17.  SHARED

2.  ANTICipate

10.  MIST13

18.  SHARQ

3.  ASHICE

11.  PACE

19.  SIGNOUT

4.  CUBAN

12.  PEDIATRIC

20.  SOAP

5.  DeMIST

13.  SBAR

21.  STICC

6.  GRRRR

14.  I-SBAR

22.  4 P’s

7.  HANDOFFS

15.  SBARR

23.  5P’s

8.  I PASS the BATON

16.  SBAR-T

"Handoff  communica-on"  now  a  JC  standard,  effec-ve  January  2010     The  JC  con6nues  to  emphasize  the  need  for  "having  a  standardized  approach  to  handoff   communica2ons"  which  moved  from  a  Na6onal  Pa6ent  Safety  Goal  to  being  scored  as  a   standard,  effec6ve  1/1/2010.      


I-­‐PASS  the  BATON   • 

Introduction: introduce yourself and your role

• 

Patient: name, identifiers, age, sex, location

• 

Assessment: presenting chief complaint, vital signs, symptoms, diagnosis

• 

Situation: current status and circumstances; including codes status, eval. of certainty, recent changes, and response to treatment

• 

Safety: concerns: critical lab values and reports, socioeconomic factors, allergies, alerts (e.g. falls, isolation)

• 

Background: comorbidities, previous episodes, current medications, family history

• 

Actions: which were taken or are required, providing brief rationale

• 

Timing: level of urgency, explicit timing, and prioritization of actions

• 

Ownership: who is responsible (eg, nurse, doctor, team), including patient or family responsibilities


I-PASS the BATON 1. 

Introduction: introduce yourself and your role

2. 

Patient: name, identifiers, age, sex, location

3. 

Assessment: presenting chief complaint, vital signs, symptoms, diagnosis

4. 

Situation: current status and circumstances; including codes status, eval. of certainty, recent changes, and response to treatment

5. 

Safety: concerns: critical lab values and reports, socioeconomic factors, allergies, alerts (e.g. falls, isolation)

6. 

Background: comorbidities, previous episodes, current medications, family history

7. 

Actions: which were taken or are required, providing brief rationale

8. 

Timing: level of urgency, explicit timing, and prioritization of actions

9. 

Ownership: who is responsible (eg, nurse, doctor, team), including patient or family responsibilities

10.  Next: what happens next (eg, any anticipated changes in condition or care, the plan, any contingency plans)


Just  go  NUTS  

•  Name  of  resident,  diagnosis,  room  number   •  Unusual  or  unique;  variances  iden6fied  on  the   individual  care  plan  including  cri6cal  lab  values,  pain   management,  etc   •  Tubes  such  as  IV,  NG,  catheters,  drains,  ostomies   •  Safety  concerns  such  as  falls,  medica6on   reconcilia6on  


S-BAR Iterations •  •  •  • 

• SBAR Situation Background Assessment Recommendation

•  •  •  •  • 

SBAR-T Situation Background Assessment Recommendation Thank residents (note: handoff done at bedside)

•  •  •  •  • 

I-SBAR Introduction Situation Background Assessment Recommendation

•  •  •  •  • 

SBAR-D Situation Background Assessment Recommendation Documentation


Agenda 1.  2.  3.  4.  5. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a.  Mentoring (Listening, Developing, Engaging, Harvesting) b.  Hand-off pneumonic c.  Daily Contracting d.  DRILLS 6.  Q&A  


A  Life6me  of  Meaning     •  Our  residents  do  not  leave  behind  their  treasure  of  knowledge   and  experience,  dreams  and  aspira6ons  when  they  come  to  live   at  Kirkhaven.     •  As  care  providers,  it  is  our  duty  to  find  the  ways  to  adapt   equipment,  rou6nes  and  the  environment,  whatever  it  takes,  to   enable  our  elders  to  con6nue  lifelong  ambi6ons  and  pleasures.    

http://www.seniorsfirst.com/kirkhaven/


“Daily  Contrac6ng”  with  Residents  

SAFE  from  FALLS  Toolkit  -­‐-­‐  h\p://www.mnhospitals.org/index/tools-­‐app/tool.362?view=detail  

1.  Verbal  contrac6ng  with  Residents  (each shift):       •  Example:    “Do you understand that you are at high risk for

falling? Will you … “

2.  Tips  to  share  with  Family  Members:   •  Example:    “Do you understand that your Mom is at high

risk for falling? Will you … ”

http://www.mnhospitals.org/index/tools-app/tool.362?view=detail


“Daily  Contrac6ng”  with  Residents  

Sample  2ps:   1.  Ask  for  help!  It  is  OK.  (weak or dizzy) 2.  Wear  glasses  or  hearing  aids,  use  them.     3.  Sit  at  the  bed  side  for  a  few  minutes  before  you  stand  up.       4.  Use  your  walker/cane/WC.   5.  Wear  shoes  or  non-­‐skid  slippers.   6.  Make  sure  your  pathway  is  clear.     7.  Tell  us  about  puddles/piles/pieces.   8.  Use  the  handrails!   9.  Keep  important  things  within  easy  reach.   http://www.mnhospitals.org/index/tools-app/tool.362?view=detail


“Daily  Contrac6ng”  with  Family*  

Sample  2ps:   1. 

Before  you  leave,  make  sure  the  call  light  and  the  bed  stand  is   within  reach.    (Phone, Kleenex, etc,)

2. 

Some  medica2ons  may  produce  weakness  or  dizziness.      

3.  Consider  staying  with  Mom  if  they  are  at  a  high  risk  for  falling  or  are   confused.   4. 

No6fy  staff  before  leaving  if  you  no2ce  confusion  or  disorienta2on   in  your  Dad.    

5.  Remind  Mom  to  ask  for  help  when  gesng  up.    


Agenda 1.  2.  3.  4.  5. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a.  Mentoring (Listening, Developing, Engaging, Harvesting) b.  Hand-off pneumonic c.  Daily Contracting d.  DRILLS 6.  Q&A  


Education - DRILLS • Everyone conducts does these, but “WHY”? • What is your goal? • Is it just to meet state requirements? • It is not a matter “IF” an event occurs that requires employees to respond properly , but “WHEN”!

Suggest there are two terms that relate to “Why” and “How” drills are conducted:


Reaction Defined as: Autonomic response to a stimulus Unfortunately, if we are not properly conducting drills, this can result in PANIC!

Response Defined as: An act of responding Let’s call this our PLAN!

Which of the above is the goal when conducting drills?


Planning vs. Panic 1.  Having a realistic and functional written plan. 2.  Accountability: Instill the importance of knowing the plan. 3.  Assess the Response: What went right, what did not? 4.  Identify the actions needed to improve and Implement them!

DOCUMENT

DOCUMENT

DOCUMENT!


Are we conducting the right “Drills”? Everyone knows their individual states requirements, but what other “drills “ should we do? •  Elopement •  Resident Falls •  Bus accident events •  Behaviors in Memory Care •  Family and outside influences


The “Goal “ Of All “Drills Should Not Be The Reaction (PANIC) but the Response that follows a “PLAN” (PERFECT) Practice helps makes perfect!


Why  Drills?  

Pictures provided by Mel Tobias


Why  Drills?  

Pictures provided by Mel Tobias


Why  Drills?  

Pictures provided by Mel Tobias


Why  Drills?  

Why  Drills?  Why  Checklists?  *  

BECAUSE  THEY  WORK  

Pictures provided by Mel Tobias


Agenda 1.  2.  3.  4.  5. 

Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a.  Mentoring (Listening, Developing, Engaging, Harvesting) b.  Hand-off pneumonic c.  Daily Contracting d.  DRILLS 6.  Q&A  


A  Closing  Thought  …  

by Henry Van Dyke


We Thank You For Your Time.


Strategies for Managing Risk in Senior Living