Residents’ Clinical Condition | Resident/Family Influences | NH Organizational Factors |
---|---|---|
Recurring acute diagnoses including sepsis, pneumonia, urinary tract infections, GI bleed, respiratory failure, DKA | Requests for transfers due to concerns about new clinical problems or exacerbations of chronic problems | Lack of NH resources to manage acute conditions such as need for suturing, management of acute illness |
Chronic medical conditions including history of seizures, chronic pain, diabetes, ESRD, CHF, COPD, multiple sclerosis, Parkinson’s, stroke, anoxic brain injury | Missed opportunities between residents/families and staff for goals of care discussions and advance care planning | NH resources available, not accessed by staff such as APRNs not consulted prior to transfer |
Repeat falls | Â | Â |
Mental health history such as anxiety, depression, alcoholism, bipolar disorder | Â | Lack of staff experience or comfort providing complex care such as managing tracheostomy tubes, feeding tubes, complex wounds |
Chronic care needs including tracheostomies, wound care, colostomies, dialysis, central lines, foley catheters, suprapubic catheters, gastric feeding tubes | Â | Missed nursing care such as missed assessment, not obtaining specimens, not obtaining vital signs |