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Don't let these sentinel events trigger falsely

SNFInfo Connection, April 6, 2002

Mention the term "sentinel event" around most long-term care professionals and it will often leave them quaking in their boots. These events are serious business.

Three of the quality indicators (QIs) will automatically trigger sentinel events and bring your facility under surveyor scrutiny-dehydration, fecal impaction, and pressure sores in low-risk residents. Here's how better documentation and care planning can help you avoid them:

  • QI 15, prevalence of dehydration. It's not uncommon to admit a resident straight from the hospital with a diagnosis of dehydration, says Bonnie Foster, RN, BSN, MEd, a long-term care consultant in Columbia, SC. Unfortunately, a hospital sometimes diagnoses a patient as such when the patient doesn't really meet the definition of dehydrated-so that the hospital can get reimbursed for the patient's care. That's why you need a written policy to address the situation.

    "Have a policy in place that states that if a resident comes from the hospital with dehydration, you'll check skin turgor, mucous membranes, etc., and if the resident's not actually dehydrated, you'll have your physician take away the diagnosis," recommends Foster.

    A telephone order will suffice for this. If the resident does meet the dehydration criteria, the facility needs to treat him or her according to its policy, she adds.

    Since the first MDS you fill out reflects care before the resident was admitted to your facility, you have until the second MDS to clear up the situation. "This will save you from the QI and the resulting deficiency," says Foster.

    Dehydration may be tough to prevent if the resident is in a decline and approaching death. But if your physician diagnoses "end-stage disease" in Section J5c, this can prove that the dehydration can't be prevented. It's also a safeguard for residents losing weight because of end-of-life factors.

  • QI 11, prevalence of fecal impaction. You can trigger this QI inadvertently if your physicians or nurses use the wrong language when writing out medication orders or nurses' notes, says Foster. Make sure the clinician does not write, "30 cc of milk of magnesia for fecal impaction," when it's not an actual fecal impaction.

    The Resident Assessment Instrument User's Manual describes fecal impaction on p. 3-108 as "the presence of hard stool upon digital rectal exam. Fecal impaction may also be present if stool is seen on abdominal x-ray in the sigmoid colon or higher, even with a negative digital exam or documentation in the clinical record of daily bowel movement."

    Despite this definition, some clinicians will still use the term "fecal impaction" for a situation that doesn't qualify. You may have to educate them on more appropriate terms to use.

  • QI 24, prevalence of stage 1-4 pressure ulcers. Since a situation where a low-risk resident obtains a pressure ulcer is considered a sentinel event, you want to be absolutely sure staff are evaluating high-and low-risk properly. "It's hard to prove it's okay to get a pressure sore, because there are too many residents out there who should have gotten them but didn't because of excellent care," advises Foster.

    She recommends having your charting and documentation for skin follow the exact wording of the MDS to clear up confusion about staging. Don't have your regular floor nurses evaluate the condition of a wound because they may not know the difference between a stage 2 and stage 3 pressure ulcer. "Go by your treatment nurse's evaluation," she says.

    "If someone is at risk for developing a pressure ulcer, you need to mark Section M5 [skin treatments] in the MDS and then show you have a program in place to heal them," she says. This written policy should include steps you take to clear up pressure sores, such as incorporating skin treatments, using pressure-relieving devices, and feeding the affected resident extra protein and vitamin C.