NURSE REVIEW

___Below is an overview of sample topics to include in a nurse review. A 90 day nurse review is like chapter notes of what has been going on with the tenant over the last 90-days. Ask yourself, what concerns do you see with this tenant. Those concerns should be reviewed within the nurse review. The concerns should flow through to the evaluation with interventions on the service plan.

  • Vitals
  • Current Health Status
  • Overview of what has been going on with the tenant over the last evaluation cycle
  • Overview of services provided to tenant
  • Review of effectiveness of interventions
  • Any falls?
  • Any hospitalizations?
  • Does tenant make routine good prudent decisions? (Give examples)
  • Is tenant able to communicate needs?
  • Review of social/activity participation.
  • Any outside service providers?
  • Overview of medication administration. Any ill-effects? Are orders current?
  • PRN Usage.
  • Is tenant appropriate for assisted living?

Tenants with a GDS of 4 or above – Elements to add to the nurse review.

  • For GDS of 4 – If tenant goes outside, describe behavior pattern. Is tenant about to make good routine decisions specific to his/her safety? (Give examples.) NOTE: Tenants with a GDS of 5 or greater should never go outside without supervision.
  • For General Population tenants who are a GDS of 4 - (Can tenant safely use household appliances such as toaster/coffee pot, household chemicals, sharp items?)
  • Is tenant able to understand and utilize emergency pendant? If not, interventions for safety checks must be identified on the service plan.
  • Does tenant have wandering/exit seeking behavior? If not, state no wandering/exit seeking behaviors.
  • Routinely refuse services? If not, state does not refuse services. If tenant does refuse…are interventions appropriate?
  • Inappropriate behaviors? If not, state does not have inappropriate behaviors. If tenant does have verbal, sexual physical behaviors…are interventions appropriate?
  • For tenants with GDS of 6 or above, describe what part of the ADL the tenant is able to perform.

Change in Condition Nurse Review

  • State why are you doing the nurse review.
  • Be clear about what the specific issue is and what changes you are making to the service plan.

Example: Gladys has had four falls within the last three days and staff report increased confusion. Staff noted she typically has walker with her. She has been forgetting to use her walker. She was unable to find apartment last night. Her last fall was approximately 6 months ago. She had one episode of a UTI at that same time. UA completed. Gladys is positive for UTI. ATB therapy for XXX days. This nurse will proceed with a significant change in condition. Service plan to be updated to include reminders/cueing specific to location within the building and reminder to use her walker. History of UTI will be added with signs/symptoms for staff to watch for and when to notify the nurse.

Discretionary Change to the Service Plan Nurse Review

  • State why you are doing the nurse review.
  • Describe the issue completely.
  • Has this issue already been identified before in evaluation or on the current service plan?
  • Describe what you are adding to the service plan.
  • Describe why this update to the service plan is not due to a significant change in condition.

Example: This nurse review is being conducted due to a recent fall in tenant’s apartment. Mildred has a fall history with fall reduction interventions identified on the service plan. Mildred has fallen three times in the past two months. On 10/15/13 and 11/2/13, Mildred was attempting to get in to bed. She slipped and fell to the floor. A positioning bar was installed to aid in getting in and out of bed. The service plan will be updated to reflect this intervention. This is not a change in condition because fall history was already identified. Intervention is a modification to current fall reduction interventions.

Trigger Nurse Review

  • State why you are completing the nurse review.
  • Describe situation.
  • Are changes required to the service plan?
  • If not a significant change in condition, explain why not.

Example: Mildred returned today from being at the hospital for several days for dehydration. She received IV fluids in hospital. On 10/20/13, Mildred was sent to ER due to being lethargic. She is glad to be back. Mildred scored low risk cognitively in May on her cognitive evaluation. No new orders with return. Service plan was reviewed and Mildred requests no changes to the service plan. This is not a significant change in condition. Service plan is appropriate at this time.