A key component in any skilled nursing facility that is working towards preventing hospital readmissions is education of the caregiving staff on their roles and responsibilities related to the ability to identify acute changes in resident’s conditions.   Before the education can begin, however, roles and responsibilities must be clearly defined for key staff members.   The following recommendations are offered:

Nursing Assistants

  • Recognize and report condition changes
  • Make frequent observations of residents condition and symptoms
  • Change of shift report:  review resident status with nursing assistants from the next shift before leaving for the day
  • Communicate findings to a nurse and request nursing follow-up
  • Advise a charge nurse or unit manager if nursing follow-up has not occurred

Staff Nurses

  • Recognize condition change early
  • Assess the resident’s symptoms and physical function and document detailed descriptions of observations and symptoms
  • Update the charge nurse or supervisor if resident’s condition deteriorates or resident fails to improve within expected time frame
  • Report resident’s status to the practitioner as appropriate

Charge Nurses

  • Ensure consistent, timely evaluation, documentation, and reporting of relevant information about the resident
  • Ensure effective communication of necessary information to other members of the interdisciplinary team who are responsible for the resident’s care

Attending/Covering Practitioner

  • If notified by telephone, listen and ask sufficient questions to arrive at a tentative diagnosis and begin workup and treatment
  • Ensure all interventions are consistent with resident’s advance directive–Communicate information to appropriate family member or responsible party to discuss change in advance directives if resident fails to improve as expected
  • Visit resident as needed to manage the situation
  • Remain in contact by telephone about the resident’s progress until resident’s condition stabilizes –Don’t assume “no news is good news”
  • Communicate with other practitioners involved in resident’s care

Education modules should be developed that clearly address each staff member and their defined roles and responsibilities related to prevention of hospital readmissions.   Educational tools and resources can be found to assist with development of education modules through Interact2 at http://interact2.net//