Case Studies

The IJ That Wasn't

Situation:
A death occurred at a facility. The resident, a hospice patient, had been actively dying. When the director of nursing reconciled medication after the death, unaccounted doses of oral liquid narcotic was noted.

Facility leadership and governance contacted 24K for assistance in completing the investigation. The state regulatory agency was notified, who handled this as a Priority One reportable.

Our Interventions:

Conducted a root cause analysis evening of event, including interview of involved staff.
Ruled out drug diversion as a root cause, as a result of investigation.
Assisted with notification of resident family and kept medical director informed and in the loop.
Developed corrective plans, to demonstrate substantial compliance before state regulators arrived next day.
Interviewed staff involved and prepared them for interview with state.
Present on-site during Priority One survey.
Drafted Plan of Correction.

The Results:

Scope and Severity turned out to be a D.
Plan of Correction accepted by state regulatory agency and desk reviewed.

Employee Turn-Over Reduced

Situation:
Facility concerned with skyrocketing employee turn-over of 78%. They asked for help in reducing this and saving money on training.

Our Interventions:

Redesigned New Employee Orientation.
Implemented 24K Team Values ™.
Conducted employee satisfaction survey and provided feedback to governance, administration, and staff.
Implemented Peer Interviews for key positions.

The Results:

In two years, employee turn-over fell to 48% and continues to trend downward.

From 13 to 4 Tags. In one year.

Situation:
In 2018, facility’s annual survey resulted in 13 deficiencies and a $12,000 one-time fine. Retained 24K for management of facility.

Our Interventions:

Completed Mock-Survey – Plus ™
Implemented 24 Karat PDSA Action Plans
Implemented 24K Team Values ™
Utilized QAPI Portal ™ and QAPI Coaches ™ to monitor compliance

The Results:

2019 annual survey: 4 tags (3 E tags, 1 F).
No fine.

Help! We are in SQC

Situation:
On last day of annual survey, facility administrator was informed they were in SQC, with 15 potential tags discussed during the exit conference. 24K retained to assist with SQC plan of correction and drafting of POC.

After engagement, facility received federal look-back survey. The CMS team was present for two days.

Our Interventions:

Immediately worked with facility staff to develop PDSA-based Action Plans to show substantial compliance with potential SQC items.
24K worked with HHSC regional staff, updating them on facility efforts for compliance.
Ownership desired new LNFA, DON, ADON. 24K assisted with recruitment and selection of these key staff members.
Our team on-site during federal look-back survey.
Developed POC and oversaw implementation of POC.

The Results:

No changes resulting from CMS Federal Look-back survey.
SQC not listed in final 2567.
Actual tags written were 11 (down from 15 proposed in exit conference).
POC accepted by state and cleared on revisit.

Decreasing Resident Antipsychotic Medication Use

Situation:
Client facility exceeded national and state benchmark averages for use of antipsychotic medication. In addition, during most recent regulatory survey, facility was cited for not having appropriate indications noted for use of prn psychotropic drugs noted in the resident’s medical records.

The facility is a Texas QIPP participating facility and by not meeting benchmark targets, the facility is missing out on potential reimbursement enhancement through the QIPP process.

Our Interventions:

24 Karat QAPI Coach™ worked with DON to develop Performance Improvement Process (PIP) team focused on PRN antipsychotic medication. The team included staff from various areas of the facility.
PIP team utilized PDSA process and the 24K QAPI Portal™ to work through continual performance improvement and development of plan of correction for survey deficiency.

The Results:

Plan of correction accepted by regulatory agency.
Facility met Texas QIPP Component 3, metric 2.

OUCH! Pressure Injuries Two Years in A Row

Situation:
During most recent two regulatory surveys, facility was cited for F-686 (Failure to Assess Risk on Admission Resulting in Acquired Pressure Injury). In addition, facility is a Texas QIPP participating facility and by not meeting benchmark target for percentage of high-risk residents with pressure.

Our Interventions:

24 Karat QAPI Coach ™ worked with DON and treatment nurse on development of Performance Improvement Process team. The team included staff, including CNA’s, from all shifts and all areas of the facility.
PIP team utilized PDSA process and the 24K QAPI Portal ™ to work through continual performance improvement.
Through 24K Rising Stars ™ meeting, staff education customized for facility staff and monthly review of audit results.

The Results:

Most recent annual regulatory visit resulted in no deficiencies related to acquired pressure injuries.
Facility has met Texas QIPP Component 3 metric one measure for 3 consecutive quarters.

We Need Fall Reduction Program

Situation:
Facility fall count was increasing for three consecutive months. The month we were engaged to partner with them to develop a fall program, the number of falls were 22.

Our Interventions:

Developed employee education program for all facility staff.
Implemented Call Don’t Fall Program.
Routine monitoring and continued education.

The Results:

Falls reduced from 22 to 4 in just 4 months.

High 5 For Hand Hygiene

Situation:
In 2017 and 2018, facility cited for Infection Control deficiency due to ineffective hand hygiene program. If not addressed, this would be a “three-peat” for facility.

Our Interventions:

Completed Mock-Survey-Plus ™
Implemented Infection Control Action Plans through QAPI Portal ™
Introduced 24K High 5 for Hand Hygiene
Monitored for compliance through 24K Rising Star ™ Meeting
Staff education and awareness campaign

The Results:

2019 annual survey had ZERO Infection Control deficiencies
No fine

CASE STUDIES