PCC UDA Triggers

Contents

Admission/Readmission of a Resident. 2

New Orders: 2

Initial Event Documentation: 3

MDS-UDA : 4

Admission/Readmission of a Resident

To be completed upon resident admission or readmission

• 6 LN: Admission/Readmission Evaluation Part 1 due immediately
  1. LN: Behavior Monitoring- - V 4 If Behavior or Psychiatric History Selected
  2. RN: Wound Assessment (Initial) will be due immediately for wounds 11-15
  3. LN: Catheter Evaluation due immediately if the resident is admitted with a catheter
  4. RN: Bladder Program Determination due by day 5 after admission/readmission, ONLY if resident is incontinent of Urine  
  5. LN: Wound Assessment (Weekly) will trigger every 7 days if the wound is present
• 6 LN: Admission/Readmission Evaluation Part 2 due within 48 hours of admission
  1. Team: IDT Meetings and Evaluations Restraint Evaluation if any potential restraints are selected.
• 7 LN: Comprehensive Care Path due in 24 hours from admission, daily x 100 days (Should be manually deactivated on day 8 if not needed)
• LN: Weekly Skin/Braden Scale for Predicting Pressure Sore Risk Admission / Weekly x 3 weeks

• LN: Weekly Skin Monitoring starts on Week 4, weekly schedule (recommended to schedule on Bath/Shower Day/Shift and should match schedule on weekly skin check order
• LN: GG Self-Care & Mobility Daily x 3 days (Including what is built into the admission)

• UM: Pain Interview due by day 5
• Team IDT: Baseline Care Plan
• Physician H&P: Due within 72 hours of admission
• SS: Social Services Assessment and documentation due day 3
• REC: Recreation Assessment and documentation (Admission)due day 3

• REC: MDS - Ethnicity/Race Interview (Readmission)due day 3
• Dietary: Comprehensive Nutrition Assessment due day 3

• MDS/IDT GG Summary due on day 4

New Orders:

Complete the 2LN: New order UDA for new orders. The following responses with trigger the listed UDA’s

•  Initial Antimicrobial (Antibiotics/Antifungals/Antiviral/etc.)
  1. LN: Focused Clinical Evaluation: Infections due q shift until Antibiotics Completed is checked on the UDA
  2. LN: McGeer’s Criteria
• New or change in pain medication:
  1. LN: Pain evaluation due immediately and then 2 weeks later
• New or change in restraint order:
  1. Team: IDT Meetings and Evaluations (Restraint Evaluation)
• New or change in Psychoactive medication:
  1. High Risk Alert to Admin tab
  2. LN: Psychoactive Medication Change note Q shift x 7 days
• NEW or Change in Coumadin (warfarin) Order
  1. LN: Focused Clinical Evaluation: Anticoagulation Monitoring due daily x 7 then weekly
• Other anticoagulant
  1. LN: Focused Clinical Evaluation: Anticoagulation Monitoring due daily x 7 then weekly
• Was this change the result of a Gradual Dose Reduction? If yes then,
  1. IDT Meetings and Evaluations - V 4 Must complete team meeting related to GDR

Initial Event Documentation:

• 1. Fall:
  1. LN: Physical function monitoring q shift x 3 days
• 2. New Skin Tear/Laceration/Abrasion (non-pressure)
  1. LN: Weekly Wound Evaluation, due in 7 days
  2. RN: Wound Assessment (Initial) due immediately 
• 3. New Bruise/Discoloration
  1. Nothing Additional
• 4. Choking/Aspiration
  1. IDT to Rehabilitation Referral Form 
• 5. New Wound (pressure)
  1. RN: Wound Assessment (Initial) due immediately
  2. LN: Braden Scale weekly times 3 weeks. (Initial Braden within 1LN)
  3. LN: Weekly Wound Evaluation due in 7 days 
• 6. Burn
  1. RN: Wound Assessment (Initial) due immediately 
  2. LN: Weekly Wound Evaluation due in 7 days 
• 7. Smoking injury
  1. Nothing Additional 
• 8. Resident to resident verbal altercation
  1. LN: Behavior monitoring Q shift x 3 days
• 9. Resident to resident physical altercation
  1. LN: Behavior monitoring Q shift x 3 days
• 10. Behavior- New or Worsening 
  1. LN: Behavior monitoring q shift x 3 days 
• 11. Elopement – Attempted but unsuccessful 
  1. LN: Behavior Monitoring Q shift x 3 days 
  2. Warning to place wander guard
• 12.   Elopement – Actual  
  1. LN: Behavior monitoring Q shift x 3 day 
  2. Warning to place wander guard
• 13. Attempted suicide
  1. LN: Behavior monitoring q shift x3 days
• 14. Other
  1. No triggers (must verify with facility leadership additional documentation required)
• If NOT completed by RN the RN Narrative Assessment UDA is due immediately
• Section F Skin Condition if you mark that a skin impairment is noted
  1. RN: Wound Assessment (Initial) due immediately 

MDS-UDA :

• Comprehensive: 
  1. UM: Quarterly Evaluation
  2. Dietary:  Comprehensive Nutrition Assessment
  3. Dietary: Mini Nutritional Assessment (MNA)
  4. SS: Social Services Assessment and Documentation
  5. REC: Recreation Assessment and Documentation
  6. Substance Abuse Evaluation (If applicable to your facility)
  7. LN: Comprehensive Care path Daily x 7 days
  8. LN: GG Self-Care & Mobility Evaluation OBRA daily x 3 days
• Non-comprehensive (Quarterly)
  1. UM: Quarterly Evaluation
  2. Dietary: Nutritional Quarterly/IPA Assessment
  3. SS: Social Services Assessment and Documentation
  4. REC: Recreation Assessment and Documentation
  5. Substance Abuse Evaluation (If applicable to your facility)
  6. LN: GG Self-Care & Mobility Evaluation OBRA daily x 3 days

• IPA
  1. Dietary: Nutritional Quarterly/IPA Assessment
  2. LN: GG Self-Care & Mobility IPA Daily x 3 days
  3. REC: MDS - Ethnicity/Race Interview
• 5day 
  1. UM: Pain Interview
  2. SS: Social Service Assessment and Documentation (Reminder – SS does an assessment that includes the BIMs/PHQ9 that automatically triggers to be due 3 days after admission)
  3. Dietary: Nutritional Quarterly/IPA Assessment
  4. REC: MDS - Ethnicity/Race Interview
  5. LN: GG Self-Care & Mobility Daily x 3 days Please Note that:  
• PPS/Planned Discharge (MDS UDA does not trigger anything, the following are processes related to PPS/ Planned Discharge)
  1. UM Pain Interview (Built into Discharge Summary therefore does not trigger)
  2. RD: (Done Discharge Summary)
  3. LN: GG Self-Care & Mobility Daily x 3 days (Manually Triggered by MDS)