| Course | NU 627 Geriatric Healthcare |
|---|---|
| Unit | Unit 7 |
| Paper type | Transitions of care plan |
| Length | About 1,040 words, 6 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN Family Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NU 627 Unit 7
Transitions of Care Plan: Hospital to Skilled Nursing Facility After Hip Fracture Repair in an 86-Year-Old Woman
Student Name
Department of Nursing, Herzing University
NU 627: Geriatric Healthcare
Instructor Name
March 6, 2026
Transitions of Care Plan: Hospital to Skilled Nursing Facility After Hip Fracture Repair in an 86-Year-Old Woman
The Move and Why
Mrs. T., a composite 86-year-old widow who lived alone in an apartment with weekly help from a niece, fell at home and fractured her left hip. She underwent hemiarthroplasty on hospital day one. On day four she can stand and take a few steps with a walker and two people assisting, and she needs help with toileting and dressing. She had a period of delirium on the night after surgery that has resolved. She is moving to a skilled nursing facility for short-term rehabilitation, with the goal of returning home. Medicare Part A covers a skilled nursing stay after a qualifying inpatient admission of at least three midnights, which she has; her admission was inpatient, not observation, and this was confirmed with case management.
Readiness
Before transfer, the following must be true: vital signs stable for 24 hours; pain controlled on oral medication; no delirium for at least 48 hours by the Confusion Assessment Method on each shift; eating and drinking adequately; bowel movement since surgery; surgical wound clean and dry; a hemoglobin that has been stable on two checks; and the receiving facility has accepted her and confirmed a bed. Each item is checked on the morning of transfer and documented.
Medication Reconciliation
Before admission, from her pharmacy record and her niece's review of the bottles at home: lisinopril 20 mg daily; atorvastatin 20 mg daily; levothyroxine 50 mcg daily; omeprazole 20 mg daily; diphenhydramine 25 mg at bedtime, over the counter; calcium with vitamin D, one tablet daily.
At discharge: lisinopril 10 mg daily, a deliberate reduction, because her blood pressure has run 100 to 110 systolic since surgery with some dizziness on standing; resume 20 mg if systolic pressure stays above 140 for three days. Atorvastatin 20 mg, unchanged. Levothyroxine 50 mcg, unchanged. Omeprazole 20 mg daily, unchanged for now; review for deprescribing at the facility. Diphenhydramine stopped deliberately, because it is strongly anticholinergic and likely contributed to her postoperative delirium; it is on the list of medications to avoid in older adults and should not be restarted. Acetaminophen 1,000 mg every eight hours, new, scheduled for pain. Oxycodone 2.5 mg every six hours as needed for pain not relieved by acetaminophen, new, for up to seven days, then review. Enoxaparin 40 mg subcutaneously daily, new, for venous thromboembolism prevention, to continue for 28 days after surgery, ending on a stated date. Senna 8.6 mg two tablets at bedtime, new, while taking oxycodone. Vitamin D 1,000 units daily, continued; calcium continued.
Every difference between the two lists is marked as intentional, with a reason, so that the receiving clinician can tell a considered change from an omission. The two most likely errors at this transition are restarting diphenhydramine from the home list and stopping enoxaparin too early.
What Travels, and to Whom
To the facility's admitting nurse and attending clinician, sent electronically before she leaves and printed in the transfer envelope: the reconciled medication list with reasons for changes; the operative note and weight-bearing status (weight bearing as tolerated, posterior hip precautions for six weeks); the delirium episode, its likely triggers, and her baseline cognition as described by her niece; the enoxaparin stop date; the last hemoglobin and kidney function results; the orthopedic follow-up appointment date; her code status and the name and number of her health care agent, her niece; and the hospitalist's direct number for questions in the first 48 hours. Handoff failures at discharge are well documented: the receiving clinician often has no summary in hand when the patient is first seen, and summaries that do arrive often leave out pending tests or medication details (Kripalani et al., 2007). The hospitalist will call the facility clinician verbally in addition to the written summary.
The Receiving Facility
The facility is a 90-bed skilled nursing facility 15 minutes from her niece. It requires, before accepting: the clinical summary, the medication list, a negative respiratory infection screen per its policy, and confirmation of Medicare Part A eligibility. It responds to referrals within 24 hours. If it declines, the second facility on her niece's list has been contacted and has a bed available within 48 hours. The facility's therapy team will evaluate her on arrival or the next day, and a facility clinician will see her within 72 hours of admission.
The Gap Before Anybody Follows Up
The first 72 hours after transfer are when adverse events are most likely to go unnoticed. In one prospective study, about one in five patients discharged from a hospital experienced an adverse event, most often related to medications, and many were preventable or ameliorable (Forster et al., 2003). For this gap: the hospital's transitions nurse will call the facility nurse the day after transfer to confirm that the medication list was entered correctly, that enoxaparin is being given, and that diphenhydramine has not been restarted; the niece will visit on day one and day three; and the facility will screen for delirium every shift for the first week.
What Mrs. T. and Her Niece Were Told
Explained in plain language and confirmed with the teach-back method: the purpose of the stay is to get strong enough to go home; the hip precautions; the blood thinner injection and why it ends on a specific date; that the sleeping pill she took at home was stopped because it can cause confusion; and the warning signs to report to the facility staff immediately: new confusion, chest pain or shortness of breath, calf swelling, increasing hip pain, or wound redness or drainage. A coaching model in which patients and family learn to manage medications and recognize warning signs across transitions reduces readmissions in older adults (Coleman et al., 2006), and her niece agreed to keep the medication list and bring it to every appointment.
What Would Count as Failure
The transition will be judged to have failed if any of the following occurs within 30 days: readmission to the hospital; a medication error involving enoxaparin, diphenhydramine, or opioid dosing; a missed orthopedic follow-up; or a new episode of delirium not recognized within one shift. Each is checkable afterward, which is the point of naming them.
References
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822
Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007
Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831
What the NU 627 Unit 7 instructions ask for
The Unit 7 assignment asks you to plan a transition for an older adult moving between care settings, such as hospital to home or to a skilled nursing facility. Expect to explain the reason for the move and the readiness criteria. Medication reconciliation is usually central, with each change marked as intentional or not. Many sections ask what information must travel, to whom and how, and what the receiving setting needs. Patient and family education should be described, often with teach-back. The period between discharge and the first follow-up is a common focus, with steps to cover it. A definition of a failed transition, such as readmission or a medication error, is often required. Cite transitional care models and evidence in APA 7. Build an invented case, and follow the length set in your classroom.
How this NU 627 Unit 7 example is built
The plan begins with the fall, the fracture and the surgery, and explains why rehabilitation in a facility is needed before she can return home. Readiness criteria are listed so the transfer is not driven by bed pressure alone. Medication reconciliation compares three sources and marks each difference, such as a new anticoagulant for a set number of days and a held blood pressure drug. The section on what travels gives each document, its recipient and how it is sent. The receiving facility's admission requirements are listed to avoid delays. The gap section cites evidence that adverse events after discharge are common and arranges a call within 72 hours. Education is described with teach-back, and the failure section defines events within 30 days that would show the transition did not work.
NU 627 Unit 7 rubric: what full points look like
Herzing rubrics for a transitions plan typically score readiness assessment, medication reconciliation, communication between settings, patient and family education, follow-up and evaluation, and evidence. Readiness points require specific criteria. Medication reconciliation is often weighted most heavily; markers look for comparison across sources with intentional changes marked and explained. Communication points go to named documents, recipients and timing. Education is credited when content is specific and understanding is checked. Follow-up points depend on covering the period before the first visit. Evaluation earns credit when failure is defined in measurable terms. Evidence points require transitional care research and guidelines, and the writing line rewards lists a receiving nurse could use as they stand.
Common NU 627 Unit 7 mistakes, and how to avoid them
Transition plans most often lose points on medication reconciliation, either by listing only the discharge medications or by not marking which changes were intentional. Students also describe communication as "a report is sent" without saying what, to whom or when. Readiness criteria are frequently missing. Education is often generic, with no method for checking understanding. The days right after transfer are commonly ignored, even though that is where many errors occur. Another gap is failing to define what a failed transition looks like, which leaves no way to evaluate the plan. Finally, include family members who will help, since in many cases they are the ones carrying information between settings.
Get a NU 627 Unit 7 example written to your instructions
Send the Unit 7 instructions and the rubric from your NU 627 classroom, plus the transition and settings your plan covers. We write a custom example with both ends specified, the medication changes marked and the gap before follow-up planned, returned in 24 to 48 hours. The first custom sample is free.
More NU 627 papers and FNP samples
- NU 627 Unit 1: Comprehensive geriatric assessment
- NU 627 Unit 2: Functional and cognitive screening review
- NU 627 Unit 3: Deprescribing review
- NU 627 Unit 4: Falls risk and prevention plan
- NU 627 Unit 5: Caregiver support plan
- NU 627 Unit 6: Goals of care conversation record
- NU 627 Unit 8: Capacity and advance care planning document
- NU 631 Unit 7: Safety screening and response protocol
- NU 632 Unit 7: Family-centered chronic condition plan
- NU 610 Unit 7: Case analysis
- NU 611 Unit 7: Diagnostic error analysis
NU 627 Unit 7 questions, answered
Why mark intentional medication changes?
So they are not undone. A receiving clinician looking at two lists that differ has no way to tell a deliberate reduction from a transcription error, and the safest-looking response is to restore the original. Marking each change with its reason preserves the clinical decision through the handover, and it is among the highest-value lines in the whole document.
What belongs in the gap before follow-up?
Somebody making contact. A phone call within a couple of days, a named person to check that medications were obtained and understood, and a clear route back if something is wrong. Most readmissions originate in that interval, and a plan that ends at discharge and resumes at the follow-up appointment has left the risky part unmanaged.
How do I define a failed transition?
Name the observable events. Medications not obtained within a set period, the follow-up appointment not attended, the receiving service not having the information, readmission within thirty days. Stating them in advance turns the plan into something reviewable, and it also tells you what to monitor rather than discovering afterwards that nobody was watching.
Where can I find a free NU 627 Unit 7 sample paper?
The full NU 627 Unit 7 transitions plan can be read here free: readiness criteria, the reconciled medication list, what travels to whom, the 72-hour gap and the failure definition. For a different transfer, request a custom plan; it is written free and normally sent within about two days.
What is medication reconciliation in a care transition?
It is comparing the medications the patient took before admission, during the stay and at discharge, marking each change as intentional with a reason, and sending one accurate list to the next setting.