Levodopa doses moved to hospital med-pass times, a dopamine-blocking antiemetic and an unconfirmed therapy referral explain one composite return in NU475's Unit 6 review, scored retrospectively with BOOST's 8P screen. Searches like "nu 475 unit 6 assignment example", "nu475 unit 6 sample" and "nu475 unit 6 example" land here.
Back in Eleven Days: A Readmission Case Review of a 79-Year-Old With Parkinson's Disease, Late Doses and an Unheard Cough
[Student Name]
Purdue University Global
NU475: Providing Transition Care - Chronic Disease and Palliative/Hospice Spheres
Unit 6 Assignment
[Instructor Name]
[Date]
Composite patient and hospital written as a model document. Dates, drugs and doses are bracketed; nothing here is a prescribing instruction.
Finding
The return was predictable and mostly preventable, and the evidence for both claims is already in the record. Of five contributing causes identified, four sit with the hospital's systems, clinicians and processes, and one with the patient. The review does not ask whether he should have come back; readmissions within 30 days are common among Medicare patients, about one in five in a national analysis (Jencks et al., 2009). It asks why this one happened and who was positioned to stop it.
Timeline
Each entry gives the day, where he was and who was responsible for him.
1. Day 1. Emergency department, then medical floor. Admitted with fever and acute confusion; urinary infection. Hospitalist.
2. Day 1. Medical floor. Home [carbidopa-levodopa] schedule of five doses, at 6, 9, 12, 3 and 6, entered as four doses at standard medication pass times. Admitting nurse and pharmacist.
3. Day 2. Medical floor. [Metoclopramide] ordered for nausea from the antibiotic; verified by pharmacy. Hospitalist and pharmacist.
4. Day 2. Medical floor. Nurse charts "more rigid than yesterday, slow to stand." Floor nurse.
5. Day 3. Medical floor. Nurse charts "coughing with lunch." Floor nurse.
6. Day 3. Medical floor. Physical therapy notes freezing at the doorway; recommends home therapy. Physical therapist.
7. Day 4. Medical floor. Delirium clearing. Nurse charts "coughing with meals again." Floor nurse.
8. Day 4. Medical floor. Home therapy referral faxed to an agency outside his county. Case manager.
9. Day 5. Discharged home to his wife. Discharge medication list prints the hospital's four-dose times. Hospitalist and nurse.
10. Day 7. Home. Agency calls to say his address is outside its service area; case manager has left for the weekend. No owner.
11. Day 9. Home. Wife phones primary care: he is "stiffer, choking on thin drinks." Message taken; callback for day 11. Primary care office.
12. Day 12. Home. Missed evening dose after a long day at his granddaughter's recital. Patient.
13. Day 14. Home. Fall in the bathroom at night; bruised hip. Wife.
14. Day 15. Home. Fever, cough, short of breath. Wife.
15. Day 16. Emergency department. Aspiration pneumonia; hip X-ray without fracture. Readmitted.
Cause Table
System. The electronic medication record converted his five-dose home schedule to standard pass times, and the discharge list printed those times. No part of the system flagged [carbidopa-levodopa] as time-critical.
Clinician. [Metoclopramide] was ordered and verified. It blocks dopamine and can worsen Parkinson's symptoms; the Beers Criteria advise avoiding it in patients with Parkinson's disease (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). A safer antiemetic existed.
Process. Coughing at meals was charted twice with no swallow evaluation requested. No one owned the step from a nursing observation to a speech-language pathology referral.
Process. The home therapy referral went to an agency outside his county. No one confirmed acceptance before discharge.
Patient. One missed evening dose after a tiring day.
From Sequence to Cause
The timeline does the persuading. Rigidity was charted on day 2, one day after his doses moved to hospital times and the same day [metoclopramide] began. Coughing at meals followed on days 3 and 4, in the days his doses ran late and his swallowing slowed. People with Parkinson's disease often report that their condition worsens during hospital stays, with medication timing a frequent source of trouble (Gerlach et al., 2012). His swallowing was already vulnerable, and late doses and a dopamine-blocking drug made it worse.
Each cause can be traced to a decision and to a person positioned to catch it. The pharmacist who verified [metoclopramide] could have suggested an alternative. The nurse who charted coughing at meals could have asked for a swallow screen. The case manager who faxed the referral could have confirmed the agency's service area. The discharging nurse could have compared the printed times with the home schedule. None of these required new resources. What was missing was a trigger that made each check routine.
The patient's missed dose is recorded honestly, but it came on day 12, after his rigidity and choking had already been reported to primary care on day 9. It did not start the decline.
The BOOST Screen, in Hindsight
Project BOOST offers the 8Ps screen for readmission risk, with items such as problem medications, polypharmacy, prior hospitalization, patient support and a palliative care question asking whether his death within a year would surprise his clinician (Hansen et al., 2013). Scored after the fact, he would have been flagged on polypharmacy, a hospitalization in the prior six months, limited support at home, since his wife is 76 and he is heavier than she can lift, and the palliative question. The screen would have marked him as high risk. It would not have named his central problem, because time-critical Parkinson's medication appears in none of the eight items.
Why No One Examined It
The Hospital Readmissions Reduction Program reduces Medicare payments to hospitals with excess readmissions after admissions for a set of target conditions, including heart failure, pneumonia and heart attack (Centers for Medicare & Medicaid Services, n.d.). A urinary infection with delirium is not among them, so this readmission carried no penalty and did not appear on the hospital's reports. That is likely why no one reviewed it until now. The causes, however, would apply to any patient with Parkinson's disease admitted for any reason.
What Went Right
Not everything failed. The urinary infection was diagnosed and treated promptly, his delirium cleared within four days, and physical therapy correctly identified that he needed therapy at home. His wife did what the system asked of caregivers: she noticed the stiffness and the choking and called primary care. The failure on day 9 was that her call became a message with a two-day callback, when rigidity and choking in a man with Parkinson's disease, days after discharge, warranted a same-day conversation.
Three Changes
1. Flag [carbidopa-levodopa] as time-critical in the medication record, so that home dose times are kept and printed on the discharge list. Owner: pharmacy informatics.
2. A nursing trigger: a second charted episode of coughing at meals prompts a bedside swallow screen and, if failed, a speech-language pathology referral. Owner: nurse manager.
3. Confirm acceptance by the home health agency before discharge, not after. Owner: case management lead.
References
American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Centers for Medicare & Medicaid Services. (n.d.). Hospital Readmissions Reduction Program (HRRP). Centers for Medicare & Medicaid Services.
Gerlach, O. H., Broen, M. P., van Domburg, P. H., Vermeij, A. J., & Weber, W. E. (2012). Deterioration of Parkinson's disease during hospitalization: Survey of 684 patients. BMC Neurology, 12, 13. https://doi.org/10.1186/1471-2377-12-13
Hansen, L. O., Greenwald, J. L., Budnitz, T., Howell, E., Halasyamani, L., Maynard, G., Vidyarthi, A., Coleman, E. A., & Williams, M. V. (2013). Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine, 8(8), 421-427. https://doi.org/10.1002/jhm.2054
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428. https://doi.org/10.1056/NEJMsa0803563
How this NU475 Unit 6 example is structured
The review argues from sequence to cause to prevention. Paragraph one gives the finding outright: the return was predictable and mostly preventable, and the evidence is in the record. The timeline then does the persuading, showing rigidity and coughing charted in the days his doses ran late, before the pneumonia. Each cause is traced to the decision that produced it and to the person positioned to catch it, the pharmacist who verified the antiemetic, the nurse who charted the cough. The BOOST screen, applied in hindsight, would have flagged him on polypharmacy, prior hospitalization, patient support and the surprise question, and the review notes that time-critical Parkinson's medication sits outside all eight items. On payment, the index stay was not one of the program's target conditions, so this return carries no penalty, which the review argues is exactly why nobody examined it. Three prevention changes follow.
Get an NU475 Unit 6 example written to your instructions
Invented records need to hold together, and the desk can assemble one from the scenario your course provides. Attach the review instructions, the rubric and any risk tool or root cause template the section names. What comes back within 24-48h is a finished review with a dated timeline and a cause table, and the first costs nothing. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
NU475 Unit 6 questions, answered
Which readmission risk tool should the review use?
Common choices include the BOOST 8P screen, the LACE index and the HOSPITAL score, each built from different variables. The sample uses BOOST because its palliative item, the surprise question, fits this course. Whatever tool you pick, apply it honestly and say what it misses, since no screen captures every condition-specific risk your patient carries.
Does the Hospital Readmissions Reduction Program apply to every readmission?
No. The program measures unplanned returns within 30 days after index stays for a defined set of conditions and procedures, including heart failure, pneumonia and COPD. A return after an admission for something else, like the urinary infection in the sample, does not count toward the penalty. Check the current condition list on the CMS website before citing it.
Can the patient in the review have a different chronic illness?
Yes. The method works for any composite patient whose return has several possible causes. Heart failure, diabetes with kidney disease and COPD are frequent choices. Send the case your instructor supplied, or describe the illness you want, and the timeline and cause table will be built around that patient's actual failure points.