2018 All-Cause Harm Prevention in Nursing Homes Change Package

Mary Madison, RN,RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

“As nursing homes across the U.S. work to prevent, detect and mitigate certain categories of harm while honoring resident rights and preferences, this change package created by Telligen in November 2018 aims to serve as a key resource to improve quality of life through safer care for the nation’s 1.4 million nursing home residents. The information applies to both short-stay and long-stay residents.”

AllCause Harm Prevention in Nursing Homes is 60-pages in length and is literally packed with extremely useful information on events that can lead to resident harm:

  •  Adverse events related to medications,including:
    • Medication-induced delirium or other changes in medical condition
    • Excessive bleeding due to medication
    • Falls/falls with injuries or other trauma with injury secondary to effects of medication
    • Constipation, obstipation, and ileus related to medication
  • Adverse events related to resident care,including:
    • Fall or other trauma with injury related to resident care
    • Pressure and other skin injury such as skin tears, abrasions
    • Exacerbations of preexisting conditions resulting from an omission of care
    • Acute kidney injury or insufficiency secondary to fluid maintenance
    • Fluid and other electrolyte disorders (e.g.,inadequate management of fluid)
    • Venous thromboembolism, deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring
    • Elopement
  • Adverse events related to infections, including:
    • Aspiration pneumonia and other respiratory infections
    • Surgical site infection (SSI) associated with wound care
    • Urinary tract infection associated with catheter (CAUTI)
    • Clostridium difficile infection (CDI)
    • Other infection related events
  • Abuse and neglect, including:
    • Mistreatment, injuries of unknown source, and misappropriation of resident property

Each of the above sections includes the following components:

a) Foundational and Ongoing Education Topics to Consider
b) Pre-Admission Practices
c) Admission Practices
d) Ongoing Care Practices and Monitoring
e)Resources to Consider

 “It is important to recognize that all staff and disciplines have a role in and should be included in organizational efforts to enhanceresident safety.”   In Appendix D, you’llsee this chart:

All 4 Appendices contain great information that your facility’s team and residents can benefit from.  Check it out!

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