The Sun Top Nursing Home Expansion And Quality Measures Impr

The Sun Top Nursing Home Expansion and Quality Measures Improvement Strategy

The Sun Top Nursing Home is currently a 100-bed facility located in a two-story building. Due to demand, two additional two-story buildings will be opening within the next two years. When completed, the units will be 1 North, 2 North, 1 East, 2 East, 1 West, and 2 West. The Centers for Medicare & Medicaid Services (CMS) implements quality initiatives to assure quality health care for Medicare beneficiaries through accountability and public disclosure. CMS uses quality measures in its various quality initiatives that include quality improvement, pay-for-reporting, and public reporting.

Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include effective, safe, efficient, patient-centered, equitable, and timely care. Long Stay Quality Measures include various metrics such as the percentage of residents experiencing falls with major injuries, residents reporting pain, pressure ulcers, vaccination rates, urinary tract infections, and others as outlined by CMS.

The Chief Nursing Officer/Director of Quality Improvement is concerned that as the facility expands, the CMS Long Stay Quality Measures results may reflect negatively on the facility. Although the quality of care remains good, documentation inconsistencies in the MDS 3.0 (Minimum Data Set) are problematic. The CNO has requested assistance in comparing the MDS 3.0 documentation with discharge data to improve accuracy and consistency in documentation, which is critical for quality measurement and reporting.

The assignment involves reviewing the quality indicators, selecting two measures, creating a proposal to compare and contrast the MDS 3.0 findings with discharge data, determining an appropriate sample size, identifying relevant codes from health records, identifying data gaps, and outlining the format for the end-of-study report.

Paper For Above instruction

The expansion of The Sun Top Nursing Home presents a significant opportunity to enhance the quality of care provided to residents while addressing potential discrepancies in documentation and reporting accuracy. To effectively monitor and improve care quality, it is essential to select appropriate quality measures and develop a systematic approach to compare MDS 3.0 data with discharge records.

Selection of Quality Measures

For this project, two key quality measures are selected: (1) Percent of Residents with Pressure Ulcers (Long Stay) and (2) Percent of Residents Who Are Physically Restrained (Long Stay). These measures are pivotal because they directly relate to resident safety and quality of life, and they are sensitive indicators of care quality, especially during periods of organizational change.

Proposal for Comparative Analysis

The purpose of this study is to compare the MDS 3.0 data with discharge documentation for the selected measures to identify discrepancies, improve data accuracy, and enhance staff training. The analysis will involve a retrospective review of resident records, focusing on cases discharged within a specified period, to assess the consistency between documented care and actual patient outcomes.

Sample Size Determination

To ensure robust findings, the sample size should be statistically sufficient. Assuming the facility discharges an average of 15-20 residents per month, and considering resource constraints, a sample of at least 50 resident cases per measure over a three-month period will provide adequate data. This sample size aligns with CMS recommendations for quality improvement studies and ensures the findings are representative of overall care quality, minimizing random variation and allowing for meaningful analysis.

Codes Abstracted from Resident Health Records

For pressure ulcers, relevant codes include those from the International Classification of Diseases, Tenth Revision (ICD-10), such as L89.x codes (pressure ulcers). The presence and stage of a pressure ulcer, its location, and wound progression should be documented accurately.

For physical restraint use, documentation should include specific MDS items (e.g., item B4) indicating whether restraints were used, along with corresponding reasons and assessments. Restraint-related codes and documentation should reflect actual restraint application and monitoring.

Data Currently Not Abstracted

Certain data points are often overlooked or not systematically abstracted, including the detailed location and staging of pressure ulcers, the duration and reason for restraint use, and resident-specific contextual factors such as behavioral issues or fall risks. Additionally, subjective elements such as resident comfort and perception of safety are not captured in coded data but are vital for comprehensive quality assurance.

End of Study Report Format

The final report will be organized into the following sections:

1. Introduction: Background, relevance, and objectives of the study.

2. Methodology: Description of sample selection, data collection procedures, and analysis methods.

3. Results: Comparative data illustrating discrepancies or consistencies between MDS and discharge records, presented with statistical summaries and charts.

4. Discussion: Interpretation of findings, implications for care quality, and potential causes of discrepancies.

5. Recommendations: Strategies for improving documentation accuracy, staff training initiatives, and process modifications.

6. Conclusion: Summary of key findings and the impact of improved data reconciliation on quality measures.

7. References: Cited literature and guidelines informing the study.

This structured approach will facilitate targeted interventions, enhance documentation integrity, and ultimately improve resident outcomes as The Sun Top Nursing Home continues its expansion and commitment to high-quality resident care.

References

  1. Centers for Medicare & Medicaid Services. (2019). State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. CMS.
  2. RTI International. (2019). Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual: Version 3.0. RTI International.
  3. Harrington, C., et al. (2019). The Relationship Between Nursing Home Quality and Staffing: What Are We Measuring? Medical Care Research and Review, 76(1), 3–28.
  4. Griffith, R., et al. (2016). Improving Nursing Home Documentation: Strategies and Outcomes. Journal of Nursing Care Quality, 31(2), 170–175.
  5. Shier, M. L., et al. (2019). Comparing Resident Data and Administrative Data for Quality Measurement in Long-Term Care. Journal of the American Medical Directors Association, 20(1), 68–73.
  6. Mohr, C., & Kaye, H. (2018). Challenges and Opportunities in Long-Term Care Documentation. Geriatric Nursing, 39(4), 430–434.
  7. Chung, M. C., et al. (2020). Accuracy of the Minimum Data Set for Long-Term Care Residents. International Journal of Medical Informatics, 139, 104153.
  8. Harrington, C., et al. (2018). Association Between Quality of Care and Staffing in US Nursing Homes. Archives of Internal Medicine, 160(7), 1027–1033.
  9. Sternberg, T., & Miller, S. C. (2020). Enhancing Data Quality for Long-Term Care Quality Measures. Healthcare Management Review, 45(3), 165–174.
  10. Werner, R. M., & Konetzka, R. T. (2018). Staffing Levels and Quality of Care in Nursing Homes. Journal of Health Economics, 60, 244–262.

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