I’ve read at various online forums tales of how CNA’s literally fill in he blanks of vital sign records- without actually getting them.

just need to vent about last night at work….another cna was to take vitals on resident on unit, she is not a regular, i am new cna and also to this ltcf. been there one week still on training.
well she was to get temp and bp..resident in hallway with me…she took temp and not bp but she wrote on vital board patients bp as 120/82…..rghghhhhh it bothered me being new i hate to start trouble but this patient cannot speak…but understands.

What if we we all did this? Blew off getting the T, P, R and B/P? What if the resident has developed high B/P and because we couldn’t be bothered to be honest, it went unchecked? What if a real temp wasn’t measured for a couple days, while the resident is coming down with a infection? What if the resident is on a new medication that has a side effect of changing their respirations, but this isn’t seen because no one took the time to count them??

This is very bad. And illegal. And unethical. And most importantly, dangerous. What’s a new CNA to do? Or an experienced CNA? You stand up and advocate for the resident. You MUST not allow this to happen, when you see it, witness it, hear about it or otherwise KNOW of it.

How do you go about advocating in situations like this?

It seems pretty simple to me. Here’s what I would do (and have done many times):
1) Tell the CNA involved that she is committing fraud and that she needs to get the VS in question, right now. While you watch.

2) Report the incident to the charge nurse immediately; explain what happened and leave your personal thoughts out of this.

3) Seek the DON and report the incident to he/she as well. In writing. ASAP…Make a copy of your report to keep for your own records. Even if the charge nurse says she will make the DON aware, go to the DON yourself. You’re covering yourself by doing so. Otherwise, it could come back to haunt you in the misconception that you were aware of the incident but didn’t report it…and so on.

DON’T BE ONE OF THOSE AIDES.
The CNA who fraudulently documents care is opening themselves up to numerous problems. They could lose their job; their certification/license; their chances to work in health care as a career will most likely be ruined for good. If actual harm came to the patient/resident because we slacked off, patients and their family can pursue legal remedy. The facility and the state body in charge of regulating CNA practice can turn the “case” over to the Attorney General and hence start the criminal justice process. You get the idea.

Trust is big in health care.
Do we really think we can trust the aide who doesn’t measure vital signs but who writes in fictional numbers?

It’s not just vital signs. When an aide fills in the blanks in this one area, I question their honesty and integrity in all areas. The box is checked for the bed bath, but did the resident really get one? There are numbers in the intake and output record, but are they truthful?

Patients trust their health care providers to be skilled and honest. Our employers, the nursing homes and hospitals and assisted living centers trust that we’re using our skills and being honest as well. Our charge nurses depend upon our skill and honesty to assist with providing timely and needed treatments and medication administration. Our co workers trust that their peers are doing the right thing for their beloved residents.

The right things mean filling in the blanks with real, honesty measured/provided numbers/care. The right thing means when something isn’t done, it’s documented as not being done. We all know there are days when we can’t get IT all done and that’s the way of this work.

Experienced aides can prioritize their work- they KNOW what care or task needs to be completed vs what can wait. New aides should feel confident to ask for direction and HELP when they need it (which might be often the first couple weeks they are on the job!)

Charge nurses should always provide guidance to help sort through these issues. When it comes to actual skills- some newer aides really have trouble measuring blood pressure. The new aide should seek the help of her mentor, or the charge nurse to really learn this skill.

Paperwork overload is no excuse!
There is WAY too much paperwork in our work. Everyone knows this. Yet, facilities don’t get paid and pass inspections if the paperwork isn’t done. In the medical chart, if it isn’t documented it wasn’t done. Sadly these are facts.

The burden of documenting has become overwhelming. The original purpose of charting was to provide a clear record of a patients’ medical condition, where members of the health care team could go to see updates and alter their interventions and treatments as needed.

The chart is rarely used for this anymore. Now, it’s a place where endless pieces of paper are stored- and kept, in the event of a lawsuit. Nurses and others document on the defensive now. This is the world many have created and our little part in it has tremendous consequences. Those vital sign numbers better correlate with the sudden medical condition discovered on the next shift. When it doesn’t, red flags are spotted and questions are asked.

Maintaining Integrity Isn’t Easy In This Work
The CNA MUST ALWAYS be honest in the care and tasks they provide. We are the front line. The first to see and know. We are extremely valuable because of our place. If we don’t feel skilled enough in providing tasks/care, we need to speak up to this and ask for help. Those of us who hear the cry for help need to be willing and able to teach. We need to recognize when a peer is having a bad time, a bad day, and offer assistance. We do this not for the aide but for the patients/residents she is assigned to.

WHY IS THIS BECOMING MORE AND MORE PREVALENT?
In the past few years I have seen an increase in aides who graduate from these small medical-skills schools who don’t have (or are not taught) the same foundations of honesty and integrity. I’m not sure honesty and integrity can be taught either…we either have these ethics or we don’t. Better screening might be one solution.

The quick turnover rates of graduating “classes” of aides amazes me- and the fact they can pass the state tests tells me they know the basics. The basics aren’t good enough anymore.

It gets lost when these fast food CNA’s get on the units and are totally overwhelmed with their assignment. They feel pressured to get everything done and this is where I often see the cheating occur. I have to wonder if these schools are not doing an adequate job teaching the students everything they really need to know. I wonder if the new aides thought the job would be much easier.

When we see cheating happen we have to speak up. Loudly at times. We might even need to make a stink once in a while. Life and death decisions are sometimes made based upon our honesty. As I said, we’re the front line. Our words have HUGE impact upon everyone’s word, all of whom are above us. If we’re not honest, then neither are they. Yet we know it, and they don’t. Remember that.

We have received some emails asking us about blogging. It’s Web 2.0…Blogs are quickly replacing the standard web site as we know it.

We’d love to see more CNA’s enter the blogosphere! There aren’t any that we know of. We have an Administrator and a Nursing Home consultant and various advocacy groups who use blogs, and MANY nurses and doctors. But CNA’s? None. CNA’s could use blogs as a way to express frustrations with their work; they can share antidotes about residents; they could learn to advocate for change. Writing (posting) about work experiences, for some, is therapeutic.

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YouTube has the series on Nursing Home Reform, 20 Years Later.

Ahoy there! We’ve been very busy this week, WORKING tons of shifts and not having ANY spare time for this site. Next week looks less busy for us so we will resume our regular posting schedules then.

Have a good weekend.

Below you will find the most popular articles of the past month. Check them out to make sure you have not missed any.

• National Nursing Assistant’s Week: June 12-19, 2008
• Asides: What Not To Wear to Work
• Job Interveiw Do’s and Don’t’s
• Spot Light: Rehabilitation/Restorative Nursing: Differences

Often we hear the terms Restorative Nursing and Rehabilitation Nursing- the two terms are confused and intermixed in conversations and services. While similar, there are a few major differences between the two:

Rehab is a higher level of skilled care. Services are always provided by licensed staff- physical and occupational therapists and their assistants; Speech-Language Professionals, Nurses and others. Services are billed for by the hour. Government and insurance plans will only reimburse services delivered by licensed professionals. The use of CNA’s in Rehab is limited- and any care they provide is not “billable”. This means services provided by a CNA are not paid for. In Rehab, the CNA is not considered a professional.

Restorative care, on the other hand, is provided by nursing staff, including CNA’s. It is provided 24 hours a day, 7 days a week. Nurses can assess residents for needs and create special programs designed to restore or maintain the residents’ current and previous levels of physical health.

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National Nursing Assistant Week is coming up. The original idea behind this week was to honor those CNA’s who have chosen this work as a career. It now includes all nursing assistants, with June 12th being specially designated for CAREER nursing assistants.

The annual observance of Career Nursing Assistants’ Day and Nursing Assistants’ Week began in Ohio in 1977 as the Ten Year Club, and expanded nationwide by request in 1985. Since that time, this popular nursing assistant recognition program has grown to include thousands of facilities and organizations joining together each year to recognize and honor nursing assistants in long-term care services.
The title, Career Nursing Assistant © was developed by the Nursing Assistants’ Representatives’ Committee of NE Ohio in 1977. Today’s nursing assistant is proud to be designated as a Career Nursing Assistant, and the terminology is now in common usage to identify the experienced nursing assistant.

Nursing Assistant Week should be cause for positive reflections of the work CNA’s do. Too often, we are looked down upon. Too often, we’re an after-thought and our input is rarely asked for. We’re the most supervised group in the medical/nursing setting yet we are expected to deliver most of the hands on care, at dirt wages. Others have high expectations of us- not for our skills and education, but for our warm bodies and names on a schedule. More emphasis is placed upon our attendance than our skills; our pay reflects society’s overall disrespect of elderly and disabled people.

The Best Way to Honor CNA’s for National Nursing Assistant Week
Spread the celebration over time…Are we only to be recognized one week a year? How hard is it to recognize our good work and value all the time? Asking for our ideas and input isn’t difficult. Saying “Thank You” every so often isn’t hard, either. Both of these ideas cost nothing in terms of money; but would be considered priceless to most CNA’s.

One thing I hear all the time, from management, is how much these week long “events” cost; the strain on the budget…well, honoring the aides doesn’t have to cost a penny. At the National Network of Career Nursing Assistants’ web site, there are many things that management can do, that might require the expenditure of a stamp or two.

…these are just a few ideas.

Also consider:

…these ideas are what MAGNET hospitals call Best Practices- and there designed to attract and keep the best nurses.

When people are involved in their work, and feel their opinion counts, they will give feedback and participate. If you’ve had problems with attendance or attitude at these celebrations, blame yourselves. Once a year isn’t enough. It’s doesn’t feel real, or honest. It’s a slap in the face. Many aides compare it to the dreaded survey illness that infects nursing homes once a year…all’s crazy and phoney for a week than life goes back to normal.

So, what about the actual EVENT? The CELEBRATION?
Here’s where these things get testy. It’s NEVER a good thing to SHARE the celebration of the work of CNA’s, with Nurses, or Housekeepers, or Dietary Staff. Each group is a very valuable part of the big picture. Each contributes it’s own important set of skills and work. Each deserves their own time to be honored. To lump everyone into one big party, once a year, is not only disrespectful of the employees, it’s disrespectful of their work.

NCNA WEEK is 7 days long for a reason. Seven days are listed with events for each day…as a guideline.

No one expects a nursing home to spend seven days celebrating. Hardly..what is expected is a concentrated effort to truly honor ALL the CNA’s employed- on all shifts including third shift and weekends. This might mean coming into the facility at midnight, or on a Sunday afternoon.

When planned ahead of time, seven days will not be necessary. When planning a major event where we want to include as many CNA’s as possible it would help to get creative with the schedule. Nothing stinks more than not being able to go to the one event designated for the aide- when he or she cannot leave the unit to attend.

A facility I worked at filled up three DAYS with events to honor the CNAs: One day was scheduled to target third shift aides; the next day was for second shift and weekenders and the third day was for day shift. Aides from ALL shifts did their own schedules to ensure coverage of the units…so, it did mean some slight overtime for more than a handful. But it was worth it. Attendance for these events was close to 100%- the only aides who didn’t show up were those on vacations.

As for “gifts” or tokens, one creative facility grew houseplants for the staff…the residents, with the activity folks, planted and grew little African violets and Spider plants. Another facility had the residents hand paint little plaques “awards”; and yet another facility utilized the local community with discounted and free coupons for pizza, groceries and gas. There’s plenty of opportunities in the local community- management just needs to seek them out.

Specific items for CNA Week are available, of course, and when possible, should be purchased. The NNCNA web site has a store, that has lapel pins, T shirts and little TIPS booklets designed just for this event.

This post was written for the management of nursing homes…I will have another post for the CNA’s on THEIR part in this.

Senator Grassley has introduced legislation aimed at increasing the transparency of nursing home ownership. This is in response to the Manor Care buy out.

Nursing Home Transparency and Improvement Act of 2008

Increases Transparency About Nursing Home Ownership and Operations

* Enables the residents and the government to know who actually owns the nursing home

* Strengthens accountability requirements for individual facilities and nursing home chains, including annual independent audits for nursing home chains

* Improves Nursing Home Compare by including a nursing home’s ownership information, the identity of participants in the Special Focus Facility program, a standardized complaint form and links to nursing home inspection reports

* Provides more transparency of a nursing home’s expenditures by requiring more detail in cost reporting

Also, added to the legislation package:

–Instead of imposing civil money penalties (CMPs) up to $10,000, the Secretary would be able to impose a range of penalties of up to $100,000 for a deficiency resulting in death, $3,000-$25,000 for deficiencies at the level of actually harm or immediate jeopardy and not more than $3,000 for other deficiencies.

–The Secretary would be able to reduce CMPs for facilities that do not appeal CMPs and for self-reporting deficiencies below the immediate jeopardy level or the actual harm level if the harm is found to be a “pattern” or “widespread” or those resulting in death.

–Penalties must be collected within 90 days, following a hearing.

* Equips the Secretary with tools to address corporate-level problems in nursing home chains by giving the authority to develop a national independent monitor program specific to multistate and large intrastate nursing home chains

* Provides greater protection to residents of nursing homes that close by requiring advance notice of the closure as well as the development of a transfer and relocation plan of residents

And for staffing:

Improves Staff Training

*Improves staff training to include dementia management and abuse prevention training as part of pre-employment training

* Requires a study on increased training requirements either in content or hours for nurse aides and supervisory staff

This is only a proposed bill.

The New York Times has an article about bed sores and team approach to preventing them.

Some highlights:

New research is suggesting that the battle against bedsores requires a team approach, enlisting everyone from nurses and nursing assistants to laundry workers, nutritionists, maintenance workers and even in-house beauticians.
[…]
“Preventing pressure ulcers is a 24/7/365 kind of job,” said Jeff West, a clinical reviewer at Qualis Health in Seattle, who helped to set up the collaborative in 2003. “It’s not as if one person can get it all done. And if it fails just a little bit, just during the weekends, for instance, you’re not going to get the results. It takes tremendous consistency.”
[…]
At the Lutheran Home in Fort Wayne, Ind., for instance, “the laundry workers helped us see that some clothes weren’t fitting the residents properly and were restricting their skin,” said Jeanie Langschied, a registered nurse there.

The kitchen staff began putting protein powders in cookies to boost nutrition. They added buffet dining, so residents would not remain in one position for so long, compressing fragile skin.

Even the beauty shop “realized that wait times needed to decrease,” Ms. Langschied said, and residents should be repositioned while getting their hair done. “It was all departments looking at everything, and it was just amazing the information that flowed through.”
[…]
At David Place, a nursing home in David City, Neb., staff members say they focused on assessing each resident’s risk for bedsores, and noted this risk on the assignment sheets used by nursing assistants.

“The residents at highest risk,” said Dan Smith, director of nursing, “would be the last up for meals and the first down after meals so they would not be in their wheelchairs for long periods of time putting pressure on their bottoms.” Residents at risk from weight loss were given yellow plates, so that staff members would remember to encourage them to eat more.

David Place also bought new mattresses made of high-density foam to reduce pressure in key areas. Staff members say they redoubled efforts to keep feet elevated with pillows so that bedsores would not develop on the heels. And they began to use new moisture barrier creams with residents who were incontinent, since lingering moisture can speed the development of sores.
[…]
Staff members at Palatka Health Care Center in Palatka, Fla., initiated a similar blend of measures. They created a “skin-watch action team,” or SWAT, to identify vulnerable residents and to make sure that their heels were floated, that they were given pressure-reducing cushions and that they were repositioned frequently, said Carol Jones, a risk manager at the center.

“We got the grass-roots level, the certified nursing assistants, much more involved, and they were held accountable,” Ms. Jones said. If a bedsore began to develop, she said, “we’d ask them, how did this happen?”

Excellent article and worth printing and sharing with everyone who works at nursing homes…and everyone includes those who we might think are vital members of a skin care team.

There’s a lot of buzz outside the world of nursing homes and other places CNA’s are employed at: It’s called THE NO JERK POLICY. Some people refer to this as Workplace Civility.

In the business community this term refers to businesses that have a zero tolerance for hiring, and keeping on staff, people who exhibit rude and mean behaviors. Customers and vendors are often expected to abide by the policy as well.

Let’s face it, nursing homes and most medical/nursing facilities are chock full of people who can be described as jerks. Managers, doctors, nurses, techs, aides, dietary and housekeeping employees- administrators, DON’s…AND, our customers- the residents and their families are very often the sources of JERK like behavior.

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