CMD Case Analysis & Practical Application 2 — Questions and Answers
Question 1: A skilled nursing facility's antibiotic usage rate is 3x the national benchmark. As CMD, what is your FIRST action?
- Immediately restrict all antibiotic prescribing
- Conduct a root-cause analysis of prescribing patterns and indications (Correct answer)
- Terminate the attending physicians with highest usage
- Report the facility to the state health department
Correct answer: Conduct a root-cause analysis of prescribing patterns and indications
A root-cause analysis identifies whether overuse stems from diagnostic ambiguity, culture-and-treat habits, or family pressure before interventions are designed.
Question 2: An 84-year-old resident with advanced dementia develops a fever of 101.8°F. The family insists on hospitalization. The care plan indicates comfort-focused goals. What is the most appropriate CMD response?
- Transfer the resident to the hospital immediately to honor family wishes
- Override the care plan and initiate aggressive workup in the facility
- Hold a goals-of-care meeting to realign family expectations with the documented care plan (Correct answer)
- Discharge the family's concerns and treat symptomatically without discussion
Correct answer: Hold a goals-of-care meeting to realign family expectations with the documented care plan
A goals-of-care conversation ensures the family understands the existing plan and allows shared decision-making consistent with the resident's documented wishes.
Question 3: Your facility reports a sudden cluster of 6 residents with diarrhea over 48 hours. As CMD, which pathogen should you prioritize ruling out FIRST?
- Salmonella
- Clostridioides difficile (Correct answer)
- Norovirus
- E. coli O157:H7
Correct answer: Clostridioides difficile
C. difficile is the most common healthcare-associated diarrheal pathogen in SNFs and requires immediate contact precautions and stool testing.
Question 4: A newly admitted resident's medication reconciliation reveals 14 active medications. Under the STOPP/START criteria, the CMD should focus on which action?
- Continue all medications to avoid withdrawal effects
- Perform a systematic deprescribing review targeting potentially inappropriate medications (Correct answer)
- Defer medication review to the community pharmacist only
- Add a proton pump inhibitor prophylactically for polypharmacy risk
Correct answer: Perform a systematic deprescribing review targeting potentially inappropriate medications
STOPP/START criteria are validated tools specifically designed to identify potentially inappropriate prescribing and trigger deprescribing in older adults.
Question 5: A SNF administrator asks the CMD to sign physician orders for a resident the CMD has never evaluated. What is the correct response?
- Sign the orders as a professional courtesy to the facility
- Sign only if the prior physician's notes are available
- Refuse to sign until the resident has been personally assessed (Correct answer)
- Delegate the assessment to a nurse practitioner and then sign
Correct answer: Refuse to sign until the resident has been personally assessed
A CMD must perform or directly supervise a personal assessment before co-signing orders to maintain licensure standards and resident safety.
Question 6: During a QI meeting, data shows the facility's pressure injury rate increased 40% in Q3. Which quality improvement framework is MOST applicable to structure an intervention?
- Donabedian structure-process-outcome model (Correct answer)
- Six Sigma DMAIC cycle
- Lean 5S methodology
- Balanced Scorecard approach
Correct answer: Donabedian structure-process-outcome model
The Donabedian model is the foundational framework in healthcare quality, linking structural inputs and care processes to measurable resident outcomes.
Question 7: A resident with COPD is prescribed supplemental oxygen at 2 L/min. Family requests increasing it to 4 L/min because 'more is better.' The CMD should:
- Increase oxygen to satisfy family and reduce conflict
- Explain that high-flow oxygen may suppress hypoxic drive in COPD and is not indicated (Correct answer)
- Order a pulmonology consult before any discussion
- Reduce oxygen to 1 L/min as a compromise
Correct answer: Explain that high-flow oxygen may suppress hypoxic drive in COPD and is not indicated
In COPD patients, excessive supplemental oxygen can suppress the hypoxic respiratory drive and worsen hypercapnia, making education on targeted saturation goals essential.
CMD Case Analysis & Practical Application 2
A skilled nursing facility's antibiotic usage rate is 3x the national benchmark.
As CMD, what is your FIRST action?