Date of Completion


Document Type

Open Access Capstone

Degree Name

Doctor of Nursing Practice (DNP)

Faculty Advisor

Eileen Stuart-Shor

Site Advisor

Jessica Plante

Second Reader

Lingling Zhang


Background: Individuals admitted to Skilled Nursing Facilities (SNFs) are at risk of preventable hospital readmissions due to complex medical issues. Evidence indicates that many residents are transferred from SNFs to the hospital at least once. The Centers for Medicare & Medicaid Services penalizes facilities with high rehospitalization rates. Implementing an evidence-based strategy could reduce 30-day readmission rates in this setting.

Local problem: This project was conducted in a 34-bed Sub-Acute Care Unit in an SNF. The unit's 30-day readmission rate was high compared to the average rate at the SNF and the national benchmark, identifying a need to reduce readmission.

Methods: The Stop and Watch (SW) Tool and the Readmission Prevention Pathway were implemented by the CNAs (n=9) and nurses (n=8) on all shifts for 12 weeks. Knowledge about nonspecific symptoms of illness, the SW Tool, and the pathway was measured using a pre-and post-educational survey and was assessed pre- and post-implementation. The frequency and proportion of daily SW Tool use were calculated. The pathway utilization was assessed by reviewing resident charts for evidence that the pathway was followed. Staff satisfaction with the SW Tool and the pathway was assessed using a survey. The readmission rate was assessed by analyzing monthly institutional data. The Knowledge to Action Framework was used to guide the process. Ethics review at the SNF determined this was a quality improvement project, not human subject research.

Results: Results showed improvement in nurses' and CNAs' knowledge of the SW Tool pre/post-education, 41.3% and 136%, respectively. There was high SW Tool utilization for all shifts throughout the intervention (>80%). Out of 32 events that triggered evaluation by the nurse, correct action was taken 96.9% of the time. Preventable 30-day readmissions decreased in the project unit (29.5% pre vs.13.3% post), representing a 54.9% improvement. Staff were highly satisfied with the feasibility and sustainability of the SW Tool and the pathway.

Conclusion: The overall outcomes were positive. Staff knowledge about the tool and readmission prevention strategies improved. The SW Tool and readmission prevention pathway were utilized and were effective in identifying and managing events. The 30-day readmission rate on the project unit decreased. Future quality improvement initiatives could scale-up implementation the SW Tool and pathway on all units of the SNF to improve the quality of care and reduce preventable readmissions.

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