Five Star
When calculating Five Star how do you determine the baseline stars?
What is by calculating survey stars
Name a high risk incident?
What is:
- Fall with fracture
- Identification of a new PU at ST III or above
- Elopement
- Suicide ideation or attempt
- Allegation of abuse
-
When do you initiate an investigation after an event?
What is immediately
What is "root cause"
What are factors that caused an event/problem and if eliminated it would prevent recurrence of the event or problem.
Its the CORE ISSUE
How many cycles are included in survey stars?
What is 3 cycles?
first cycle = 1/2
second cycle = 1/3
third = 1/6
Immediate notification of a high risk incident includes
What is notifying your Corporate Director of Clinical Services, Regional Nurses
What is the preferred way of obtaining statements?
What is assign a team member to develop question to be asked and the team member asks the questions and writes the statement
What are the steps in RCA
-Identify the event/problem to be investigated
- Identify team
- describe what happened - FACTS
- identify contributing factors
- identify root causes(s)
- design implement a plan to mitigate
- Measure success
How are stars added and/or subtracted from the baseline stars?
What are with QM and Staffing?
Name at least 2 steps that need to be included in your analysis of a high risk incident
What is:
- Steps taken to protect the individual resident(s)
- Steps to identify and protect "like" residents
- System or process affected and what needs to be put in place with timeframes
- What educational presentations need to be developed and trained
Who is responsible for on-going monitoring?
Name ways you can understand the cause of the incident/event
What is:
- Interview staff
- Interview roommate or other resident who were present
- Observe the environment
- Review the chart (medications, history, etc)
When is a RCA done?
Really any event
as soon as possible following an event
Name at least one Nationwide process that is proactive in achieving stars?
What is clinical meeting?
What is clinical rounding?
What is using Critical Element Pathways?
What is clinical risk meeting?
How do you report to the state?
What is put in the factual information about what happened and ask to be put in pending until investigation is complete
Timeframe for completing inventions
What is within 72 hours but no longer than 5 days
Who are the participants in the RCA?
Who are
Facilitator
Individula involved in the event
person(s) with first hand knowledge
Key leadership-QAPI team
How does an IJ PNC affect your survey points?
What is decrease survey points to 20?
How long do you have to complete your investigation for state reportable events?
What is 5 days
How is the investigation "wrapped up"?
What is conclude the investigation with a summary of what occurred including the information the conclusion is based on
What are the RCA ground rules?
Keep an open mind
don't seek blame but understanding
treat failure as the best learning experience you can hope for