The Changes CNAs See First and How to Pass Them On

Long before a resident's vital signs look alarming, someone usually notices that something is off. Most often that someone is a certified nursing assistant. CNAs help residents eat, dress, walk and use the bathroom every day, so they see small changes before anyone else does.

The hard part is not noticing. It is making sure what a CNA noticed reaches a nurse, gets documented and is acted on by the care team.

The Everyday Changes That Matter

Early changes in a resident's condition are rarely dramatic. They tend to look like a slightly different day. Common examples include:

• New swelling in the feet, ankles or legs, or shoes that suddenly feel tight
• Eating or drinking less than usual, or leaving most of a meal tray
• New confusion or sleepiness, such as dozing through activities or not following a conversation they normally would
• A change in mobility, like needing two people for a transfer that used to take one
• Breathing changes, such as getting winded with less effort or needing to sit up to breathe

Any one of these can be the first visible sign of an infection, dehydration, a heart failure flare or a medication problem. None of them is a diagnosis. Each one is a reason for a licensed nurse to take a closer look.

Stop and Watch: A Simple Way to Speak Up

The INTERACT program (Interventions to Reduce Acute Care Transfers) includes an early warning tool called Stop and Watch. Each letter of the name prompts a type of change, such as "Seems different than usual," "Talks or communicates less," "Ate less," "Drank less," "Weight change," "Tired, weak, confused, or drowsy" and "Help with walking, transferring, toileting more than usual."

The instructions are short: if you notice a change, circle it and tell a nurse, then give the nurse the form or review it with them as soon as you can. A quality improvement training from Alliant Health Solutions notes the tool can be used by any staff member in any department, on paper or built into the electronic record.

That last point matters. Housekeepers, dietary aides and activity staff also notice when a resident "just isn't themselves."

SBAR: Turning an Observation Into a Clear Report

Once a nurse hears about a change, the next step is often a call to a provider. INTERACT's SBAR form helps the nurse organize that call:

• Situation: what is happening right now
• Background: the resident's relevant history and recent changes
• Assessment/Appearance: what the nurse is seeing and measuring
• Recommendation/Review and Notify: what the nurse is asking for, and who was notified

The form prompts the nurse to gather information by body system before calling. That way the provider gets a complete, concise picture and can make an informed decision. The CNA's original observation becomes part of the record instead of a passing comment in the hallway.

What the Research Shows, Honestly

The early evidence for INTERACT was encouraging. In a 2011 study in the Journal of the American Geriatrics Society, Ouslander and colleagues followed 25 nursing homes using INTERACT II for six months. Hospitalizations fell 17% overall compared with the same months a year earlier. The 17 homes rated as moderately or highly engaged saw a 24% reduction, versus 6% in the 8 less engaged homes and 3% in 11 comparison homes.

A later, more rigorous test was less positive. A 2024 pragmatic randomized trial by Phibbs and colleagues, also in the Journal of the American Geriatrics Society, introduced INTERACT in 8 Veterans Health Administration community living centers and compared them with 8 matched control sites. There was no significant difference in all-cause hospitalizations. Only 5 of the 8 intervention sites substantially engaged with the program, and inappropriate transfers were already low at baseline.

Put together, the two studies point to the same lesson. The forms do not prevent hospital transfers on their own. Results depend on whether staff actually use the tools every day and whether the facility has room to improve.

Quick Checklist: Making the Tools Part of the Shift

• Keep Stop and Watch forms (or the electronic version) where CNAs can reach them on every unit and every shift.
• Tell CNAs plainly that reporting "something seems different" is expected and welcomed, even if it turns out to be nothing.
• Close the loop: let the CNA know what the nurse did with their report.
• Review a few recent changes in condition at a monthly meeting to see whether early observations were captured and passed on.
• Ask your medical director and providers which SBAR elements they want included when nurses call.

A daily risk screen can help by pointing the team toward newly admitted residents who are most likely to change, so the people watching know where to look first.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.