4. Abnormal findings — the necessity chain
Finding → severity → comparison → risk → intervention → notification (provider + representative) → orders → response → reassessment.
Model abnormal 1 |
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Early sepsis surveillance triggered: a new fever of 101.6°F with a heart rate of 110, a respiratory rate of 22, and new confusion in a resident with a possible source (a wound/urinary/respiratory focus) — concerning for sepsis. A focused assessment for the source completed, the sepsis pathway initiated per protocol, SBAR to the provider with the constitutional picture, orders received (labs/cultures, evaluation, possible transfer), and the responsible party notified; the resident placed on close monitoring. Will reassess on the ordered frequency; supports the Section I update. Skilled recognition of the systemic change required — a daily SNF-level need. |
Model abnormal 2 |
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Generalized decline / failure to thrive: a progressive drop in intake, energy, and participation with weight loss over the week, without a single localizing cause — the multi-problem plan re-evaluated, the provider and dietitian notified, a workup for reversible causes ordered, goals-of-care revisited with the representative as appropriate, and the care plan revised. Will reassess; supports the Section K update. Skilled management and evaluation required to integrate the decline and adjust the plan. |