Clinical Services Monthly Report

Clinical Services Monthly Report 

Policy 
The Director of Nursing Services (DNS) is responsible for completing the Clinical Services Monthly Report. This report is in Excel format and contains 12 months of data. The report for the previous month must be completed and forwarded to the Director of Quality and Clinical Services and the facility’s Clinical Specialist via email by the 5th of each month. The following reports should also be included: Acute Hospitalizations for the previous month, QIQMs (6-month report ending the last day of the previous month), Staff Development Calendar for the current month, FA/CA Pressure Ulcer Report (cumulative report), and Monthly Infection Control Report for the previous month. 

Procedure 

1. Report Completion: 

• Enter the Facility Name on the first page of the report. 

• Complete each section of the report as indicated. The form will convert data to percentages where noted. 

2. Sections to be Completed: 

Census: 

• Enter the appropriate numbers for each entry listed. 

Falls: 

• Enter the total numbers for each entry. 

Low Beds: 

• Enter the number of residents using a bed in the lowest position as a fall intervention. Do not count beds slightly lowered to adjust to the resident’s height. 

Restraints: 

• Enter the number of residents using a restraining device and list the types of devices used. 

• Use the following key: 

• SB = Seatbelt 

• LB = Lap buddy 

• MW = Merriwalker 

• T = Tray 

• Enter the initials of any resident newly restrained during the month. 

• Enter the initials of all residents currently utilizing a restraint. Indicate if a restraint was discontinued during the month. 

Alarms: 

• Enter the number of residents using an alarm. Count the location of the alarm (bed, chair, door) as one alarm. 

• Enter the number of bed alarms, chair alarms, and other alarms. 

QI/QMs: 

• Review the QI/QM report - “Facility Quality Measure/Indicator Report.” 

• Enter the total number of indicators ≥ 75th percentile rank. Include any indicator in the next entry. 

• Enter the number of indicators ≥ 90th percentile rank. 

• Send the “Facility Quality Measure/Indicator Report” as an email attachment with the Clinical Services Monthly Report. 

Infection Control: 

• Refer to the facility’s “Monthly Infection Report.” 

• Enter the number of residents with nosocomial infections. 

• Enter the number of residents treated for asymptomatic infections. 

• Send the Monthly Infection Report as an email attachment with the Clinical Services Monthly Report. 

Pressure Sores: 

• Refer to the “Facility & Community Acquired Pressure Ulcer Report.” 

• Enter the census on the last Sunday of the month. 

• Enter the number of residents with facility-acquired pressure sores on the last Sunday of the month. 

• Enter the number of new pressure sores developed during the month. 

• Enter the number of residents with new pressure sores that developed during the month. 

• Send the Facility & Community Acquired Pressure Ulcer Report as an email attachment with the Clinical Services Monthly Report. 

Dietary: 

• Obtain assistance from the Dietitian and/or Director of Dining Services. Do not use the MDS or QI/QMs for this information. 

• Enter the number of residents on supplements, modified consistency diets, and thickened liquids. 

• Enter the number of residents with 5% avoidable weight loss and new residents with 10% avoidable weight loss (compare the previous month’s weight to the current month’s weight). 

• Avoidable weight loss should not include planned weight loss, weight loss due to diuresis, or weight loss due to hospitalization. 

Psychotropic Medications: 

• Refer to the Pharmacy Consultant Report or ECS. 

• Enter the number and percentage of residents on antipsychotic, anxiolytic, antidepressant, and sedative/hypnotic medications. 

• Enter the initials of newly placed residents on antipsychotic medications. 

Interdisciplinary Care Plan Attendance: 

• Refer to the facility’s IDT Care Plan Attendance Audit. 

• Ensure the number “20” is in the box following “Number Audited.” 

• Enter the numbers for Resident, Family, Charge Nurse, CNA, Social Worker, Dietary, and Recreation attendance. 

• Indicate “Yes” or “No” for “Should Rehab be Present?” and “Was Rehab Present?” 

• Calculate the Rehabilitation attendance percentage. 

Report Submission: 

• Send the completed Clinical Services Monthly Report along with the following reports as email attachments by the 5th of each month: 

• Acute Hospitalizations for the previous month 

• QIQMs (6-month report ending the last day of the previous month) 

• Staff Development Calendar for the current month 

• FA/CA Pressure Ulcer Report (cumulative report) 

• Monthly Infection Control Report for the previous month 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS