A2

Cognitive decline affecting medication safety

Skilled cognitive assessment found a decline from baseline — new recent-memory impairment and reduced executive function on the Mini-Cog — with evidence of missed and doubled medications attributable to the decline; the level of consciousness is stable and there is no acute fluctuation suggesting delirium. Findings indicate a cognitive decline compromising medication safety. Provider notified at 12:30 with the cognitive findings and the medication errors; order received to set up a supervised medication system and evaluate the decline. A reminder-and-supervision system was established and the caregiver educated; teach-back accurate. Reassessment of cognition and medication safety planned next visit. (Medication-management plan in the Function and Safety references.)

A3

Behavioral symptoms of dementia

Skilled cognitive assessment found new agitation and suspiciousness in a patient with dementia, without an acute change in the level of consciousness or a clear delirium precipitant on initial review. Findings indicate behavioral and psychological symptoms of dementia, with delirium to be excluded. Provider notified at 11:00 with the behavioral change and the screen; order received to evaluate for a precipitant (including pain, infection, and constipation) and to review the approach. The caregiver was coached on non-pharmacologic supportive strategies — a calm environment, routine, and redirection — and safety; teach-back accurate. Reassessment of behavior and any precipitant planned next visit.

A4

New disorientation with a wandering risk

Skilled cognitive assessment found new disorientation to place and time with reduced situational awareness, creating a wandering risk in a patient who lives with a caregiver. The course appears subacute; delirium is being excluded. Findings indicate worsening disorientation with a safety risk. Provider notified at 10:45 with the cognitive change and the wandering risk; order received to evaluate the change. An urgent safety plan was developed with the caregiver — supervision, door alarms, and identification — and reorientation strategies were taught; teach-back accurate. Reassessment of cognition and the safety plan planned next visit. (Wandering safety plan in the Safety reference.)

A5

Fluctuating consciousness — urgent

Skilled cognitive assessment found a fluctuating and reduced level of consciousness — the patient was drowsy and difficult to engage, alternating with brief alertness — a marked acute change from baseline with inattention and a positive CAM. Findings represent acute delirium with an altered level of consciousness requiring emergency evaluation. Given the reduced consciousness, the provider was contacted immediately at 09:30 and emergency response activated per protocol; the patient was kept safe and monitored, with serial level-of-consciousness checks documented while awaiting transport, and the caregiver informed. The event and communications were documented, with follow-up to coordinate care on return. (Precipitant and vital-sign review with Vital Signs.)

A6

Capacity concern affecting safety

Skilled cognitive assessment found impaired judgment and executive function affecting the patient's ability to make safe decisions about care and medications, in the context of progressing cognitive impairment without an acute change. Findings indicate a decision-making-capacity concern affecting safety. Provider notified at 12:15 with the cognitive findings and the specific safety implications; order received to coordinate a capacity evaluation and involve the care team and the designated decision-maker as appropriate. The caregiver and the designated decision-maker were engaged in the safety plan, and supportive strategies were reviewed; teach-back accurate. Reassessment and care-team coordination planned.