F309 Quality of Care Audit Tool

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable

physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care

Evaluation Area / Res. #1 / Res. #2 / Res. #3 / Comments
Yes / No / Yes / No / Yes / No
Non-Pressure Related Skin Ulcer/Wound
Evidence of documentation to support clinical dx. of non-pressure related skin ulcer/wound
Arterial Ulcer:
Appropriate Diagnosis?
PVD,significant vascular disease, generalized arteriosclerosis, inflammatory or autoimmune disorder,
Describes the wound bed as dry and pale with minimal or no exudate?
Location is in the distal portion of the LE or over the ankle or bony areas of the foot (top of the foot or toe, outside edge of the foot
Pain is increased when legs elevated, or decreased when hanging down?
Surrounding tissue:
Described as absence of pedal pulse, coolness to touch, blanching with elevation, delayed capillary refill, hair loss on top of the foot and toes, toenail thickening?
Venous Ulcer (previouslyknown as stasis ulcer)
Appropriate diagnosis? venous hypertension, dvt, obesity, malignancy, paralysis, venous insufficiency
Wound bed described as moist, granulating, superficial, minimal to copious serous drainage?
Is there pain? May experience pain that increases when foot is in dependent position
Surrounding Tissue: Described as dry scaly crusts, dilated superficial veins, tan or purple areas. Cellulitis may be present if infected?
Location described as of the lower leg often around the medial ankle
Diabetic Neuropathic Ulcer
Diagnosis of DM and have peripheral neuropathy
Location described as on the foot, at mid-foot, at the ball of the foot over metatarsal heads or ontop of the toes with Charcot deformity.
Evaluation Area / Res. #1 / Res. #2 / Res. #3 / COMMENTS
Pain Symptoms/ Being treated for pain,or who has the potential for pain symptoms r/t conditions or treatments
Care Process for Pain Management

Pain assessment upon admission, quarterly and with change of condition
Interventions/approaches to manage the pain
Using specific strategiesfor different levels or sources of pain or pain-related symptoms
Interventions to address the pain based on the assessment, clinical rationale, and resident’s goal
Interventions to try and prevent or minimize anticipated pain
Use of pain medications to balance desired level of pain relief with avoidance of unacceptable adverse consequences
Monitoring appropriately for effectiveness an/or adverse consequences
Modification of approaches as necessary

Care Plan for Pain Management
Are pain management goals measurable, reflecting resident needs and preferences?
Pertinent non-pharmacological and/or pharmacological interventions are included?
Are there time frames and approaches for monitoring the status of the resident’s pain, including the effectiveness of the interventions?
Have significant medication-related adverse consequences been identified (falling, constipation, anorexia, drowsiness) with a plan to minimize these consequences?
Is there documentation of cause and characteristic of the pain, aswell as factors influencing the pain?
Does the care plan coincide with the MDS?
Was the MD notified with changes in pain level or pain management?
Was the resident’s representative notified of significant changes in r/t pain management and/or the plan of care for pain?
Does the care plan coincide with the pain assessment
Evaluation Area / Res. #1 / Res. #2 / Res. #3 / COMMENTS
Assessment / Yes / No / Yes / No / Yes
Does the assessment identify the pain indicators and the characteristics, causes, and contributing factors related to pain?
Is there identification of a history of pain and related interventions, including the effectiveness and any adverse consequences?
Is there identification of the impact of pain on the resident’s function and quality of life
Is there identification of the resident’s response to interventions including efficacy and adverse consequences, and any modifications of interventions?

Evaluator:______Date:______

Facility:______

Quality of Care Resource Manual 2009