Much of the work we do is aimed at keeping our residents clean, dry, fed, toileted and hydrated. We focus on these things because it is OUR job. There are other things though, that often get lost in the daily shuffle. I work for an agency as a part time job (as well as a full time job at a rehab facility) and through my experiences here, I’ve seen a lot of rushed care and the results of it.

When working short, there’s a saying among aides: Face, Hands and Butts. FHB. This means that our time should be spent washing faces, hands and butts and the rest can go unattended. This isn’t ideal but it is the reality when we’re pressed for time.

Even when our units are well staffed I have seen some pretty poor quality cares that leave me wondering if some of us cannot put ourselves in our residents’ shoes…

No matter how short staffed, we must always consider resident dignity.

Complete bed baths, whirlpools and showers can be postponed.

Washing faces doesn’t mean simply wetting a wash cloth and wiping it over a face. It means using gentle soaps/cleansers. It means using another wash cloth dampened with water, to rinse off the soap. It means paying close attention to the eye areas, removing the residue and drainage we often see. It means making sure noses are clean and the area around mouths is clean as well. Shave the men.

Oral care MUST always happen- how would YOU feel if your teeth weren’t brushed???

Care must be given to underarms. They need to be washed, rinsed, dried. If needed, a light coat of deodorant is called for. Body odor is a major dignity issue for our residents.

Hands have to be washed. Period. Several times each shift. Nail care can wait, unless they are long and ragged or dirty.

Incontinent care has to happen. Buts and other areas MUST be cleaned. Period. No skimping here.

I can’t count the times I have witnessed residents being brought out with messy hair, or worse, with hair dos that are not becoming to them. Ladies like to look presentable. Imagine how you would feel with greasy, slicked back hair…it’s up to US to make hair look nice. Hair should be combed/brushed no matter what; if ladies’ hair is permed, a little spritz with some water often works wonders to bring back some curl.

Clothing choices? It usually doesn’t matter when it comes to staffing issues. Residents have clothes and we assist them with dressing. BUT what does matter is matching colors at best and avoiding clashes at worst: Striped shirts do not go with plaid pants! Just like an elegant fluffy blouse doesn’t go with sweatpants. Some of our male residents prefer to wear t shirts under their tops; and MOST of our ladies like to wear bras. Don’t skimp on this.

A quick note about briefs: For the residents who use them, we have to ensure they are correctly applied. The right size is paramount. Too big a brief is not only wasteful but a major cause of discomfort. Small briefs often lead to nasty red marks in the groin areas. Make sure the brief is centered, and the front portions are pulled up enough to allow for movement. Don’t let the brief bunch up anywhere.

Residents who use wheelchairs need special attention for comfort AND skin issues. This is a no brainer but I have seen countless times, bunched up shirts in the back and sides. Pants that are wedged up in front. We need to make sure these things don’t happen. Take the time to pull down tops once a resident is positioned in their W/C; fix the wedgies and pull down the lower parts of pants. Make sure the resident is seated properly and is comfortable.

As much as most of us don’t like providing less than ideal care, we can do so on shifts where we just don’t have time. Assignments are often increased with two or three residents when there’s been a call out. Always check with the charge nurse about your priorities when staffing is an issue. Better yet, ask the nurse for a meeting with all the aides on the shift, to plan ahead for those times.

Always consider safety, comfort and dignity. Some will say not always in that order, either.

Two resources for CNA’s and other direct care workers for learning.

Self study articles from the state of Oregon’s Community Nursing Tools site; these are all in PDF:
Aspiration
Challenging behaviors - Part 1
Challenging behaviors - Part 2
Constipation
Dehydration
Documentation guidelines
Fall prevention
Infection control
Influenza
Medical terminology - Part 1
Medical terminology - Part 2
Medication safety
Pain management
Pneumonia
Quality care - without restraints
Your body - changes through the years

And this, ABUSE PREVENTION TRAININGS, again, in PDF. Facilitators Guides for each module are available as well.
Module 1: Person-Centered Care
Module 2: Identifying Potential Signs of Abuse & Neglect
Module 3: Abuse and Neglect – Defining & Reporting
Module 4: Stress Triggers and Trigger Busters – Life Influences
Module 5: Stress Triggers and Trigger Busters – Job Challenges
Module 6: Stress Triggers and Trigger Busters – Client Behaviors
Module 7: Stress Trigger Signals
Module 8: Active Listening
Module 9: De-escalation – Conflict Resolution
Module 10: De-escalation – Client Behaviors
Module 11: When Abuse Happens
Module 12: Active Communication – Learning Circle

The most popular posts for the month of April, as determined by the numbers of emails about them, comments and page views.

Professional Boundaries

The 7 Habits of Highly Effective CNA’s

Asides: Managing YOUR Anger

Spot Light: Filling In The Blanks

7 Habits of Highly INeffective CNA’s

Survey Lessons: Resident Dignity and CNA’s

ALLNurses: Offer A Free Resource Page for Nurses and CNA’s!

One of the things so many people like about the Culture Change movement is the upside down chain of command structure. Residents call the shots; next the CNAs have this “power”. Nursing homes that are seeking to change their culture often do a lot of window dressing but actually change very little of the management and leadership culture. Fear is the reason for this.

When a facility is looking to really change, actions do speak very loud. Pioneer Network has been working tirelessly to assist nursing homes and assisted living facilities with culture change. Matt over at Setting The Nursing Home On Fire found this gem of an article at the Pioneer site:

Low Cost Practical Strategies to Transform Nursing Facilities
it is a pdf report.

One of the things I noted quickly was the attention to the staff break room. When the staff are respected and trusted, it shows in many ways. Having a retreat style break room is a viable and cheap idea most nursing homes could manage. With the right motivational leadership, the nurses and aides would be more than willing to assist with creating this room.

Staff Amenities
Overall Goal:
Routinely staff members have been assigned break room space in the basement of a facility that is
furnished with cast offs, has equipment and appliances that often malfunction, and space that is expected to serve the dual purpose for staff who want to socialize as well as those who want a quiet time. Reverse this trend and provide staff with an abundance of spaces including tables in main dining room, a computer station and quiet space for reading or meditation.

Really now? Do staff need all this? DO we really care if our break room is nicely outfitted with decent working microwave ovens and fridge large enough to accommodate ALL our bagged meals and drinks? And who has a computer in their break room? Management would never trust the staff to go online because they might be wasting time, right?

Get with the times, management.

Examples of Improvement Strategies:
• Enhance the staff break room. It should have good lighting, comfortable chairs, conversation arrangements, appliances that work, flat surfaces for both eating and writing and a quiet corner

• Provide computer area or computer station for private staff use

• Designate a table and regular day as “give-away or exchange” where children’s clothes, extra produce from gardens, reading material, videos, and other items can be exchanged or given away

• Provide prayer corner or small meditation room designated for staff

• Encourage staff to use lounge or dining spaces to hold baby or wedding showers or other celebratory events. Invite residents to participate along with members of the community

A big bulletin board might be the only resemblance to the “old” break room.

Wow. Comfortable chairs and seating arrangements that mirror a living room more than a waiting room? Why not? When respected, staff deserve such spaces. Most of the furnishings for such spaces can be purchased cheaply through group purchasing associations, trade group memberships and, the old fashioned way- yard sales and thrift shops.

Another GREAT source of help is the resident families. I am quite sure most would donate a chair or small table; an area rug and some table lamps. The residents themselves could make wall quilts and other artwork. Bookcases and ottomans (YES- so the tired feet of CNA’s have a place to rest UP on);
everyone has a book or two they would be willing to give to the new staff LIBRARY located in the break room (same with DVD’s and the TV/Player to go with it).

Think outside the lead box. A transformation can happen within a week if it is truly wanted. Under the culture change movement every room has significance and front line staff have much more value and respect.

Another example of how CNA’s can have a huge impact upon the survey of a nursing home. The following are samples of a real surveyor’s findings; then we’ll look at how the CNA could have prevented these scenarios from ever occurring in the first place.

1. Interviewable sample resident #2 was admitted to the facility on 2/6/01 with diagnoses including rheumatoid arthritis and a thyroid disorder (according to the face sheet). The quarterly Minimum Data Set, dated 6/12/07, coded the resident as having mild short term memory loss.

Observations of the resident on 7/1/07 at 10:30 a.m. revealed a certified nurse aide (CNA) was preparing to transfer the resident from her bed into a wheelchair using a Hoyer lift. The resident stated she needed to go to the bathroom prior to being transferred. The CNA stated the resident experienced pain using the toilet in the bathroom, so he had her go in the trash can by suspending her in the lift and placing the trash can underneath her.

A follow up interview was conducted with the CNA at 1:55 p.m. The Unit Manager was present during the interview. Both stated the day shift and evening shift used this method to toilet the resident. The Unit Manager stated the night shift had the resident use a bedpan, and did not get her up.

And:

On 7/1/07 at approximately 1:00 p.m., supplemental sample resident #27 was heard calling for help in a loud voice. The resident was seated in a wheelchair in the Silver Key office and appeared in no distress. There was a CNA seated in the Siver Key (sic) office with the resident. The CNA stated that was her job for the day, to sit with the resident. The resident could be heard calling for help in the hall outside the office. The CNA asked the resident several times why she was calling for help when there was nothing wrong. The resident yelled for help again and the CNA stated, “You are just a problem child.”

In the first example. the staff used a mechanical lift and trash can to assist with toileting a resident. Is this normal? Is this digified? What are some options?

Commodes: They make commodes in all sizes and shapes, out of soft and hard plastics. Most CNA’s have seen these PVC models. The CNA’s are the resident’s advocate. In this case they should have (and perhaps did) ask for a comfortable commode for this resident to use.

Bed Pans: They also come in many shapes and sizes. Some are made of softer plastics as well. The CNA’s should always encourage the resident to use this before getting OOB.

In the second example things aren’t so clear. Just the name of this room suggests dignity is an issue. When a CNA is expected to be a sitter, they need to have clear expectations of what they are to do with the resident. Just sitting there and watching them often isn’t enough and is very undignified. Usually a resident who needs 1:1 supervision really needs to be occupied. To be kept busy and somewhat distracted.

The CNA’s working with this resident could have foreseen situations where 1:1 time would be needed; and anticipated the need for activities and other things to do. Seeking the help of the Activity Director or other person, puzzles, board games, reading materials or any number of other items could have been available. Smart aides know these times will come and have a box of items at the ready for these moments.

We never tell a resident they are a “problem child”. To do so is border lining on verbal abuse.

To wrap this up, when we are caring for a resident who has special equipment needs for ADLs, ask to see one of the medical supply books to see what is available. If you find something that will work ask for it to be ordered.

Plan ahead. Anticipate needs. Ask for equipment. If your facility employs the services of a physical and/or occupational therapist, seek out their input on resident comfort and equipment issues. Document all of this in your personal log. Ask the charge nurses to document equipment requests in the resident’s medical records.

If you’re a smoker, you’ll want to read this article. If you’re not, you should still read this.

At work smokers take their breaks and usually light up. Having that cigarette often relaxes us and keeps us even keeled. Many facilities are now smoke free- no smoking on the actual grounds of the property or within certain distances from the buildings. BUT most allow staff to smoke inside their vehicles. This is a privilege and not a right. Be grateful when you can.

One thing is noticed often by smokers and non smokers alike: After you have smoked, YOU SMELL like cigarettes. It’s the natural course of events here. The smell gets in your hair, your uniform, your skin. And your breath. It’s not a nice thing to smell.

Do yourself and everyone else a favor: Clean up after a smoke…when you come back inside, WASH your hands first of all. Then brush your teeth or at least use some mints or gum. Some aides I know also do a little more: They use the hand gels to help rid their body of the scent. How? They simply rub the gel in their hands and before it dries they quickly rub it all over their arms, neck and uniform top. It works wonders. One aide actually briefly runs her gel soaked fingers through her hair as well.

Other aides wash up and then use a lotion with a light scent, to cover up the odor. At a local nursing home down the road from me the staff use the unscented Febreeze-like spray over themselves- this is probably the best thing I have seen yet, that really works.

Residents and patients can get nauseated when they smell cigarette odors. Others may become agitated because they WANT to smoke but cannot. Either way, it’s gross and no one likes the smell. So be considerate of others.

Often times we wonder what information we should report to the nurse at the end of shift…most of us are very good with sharing the medical and nursing info. But what about the other things?

The following is an example of how our lack of sharing/reporting can have such an adverse effect on our residents. This is from an actual state survey of a nursing home in Colorado.

Interviewable sample resident #1, a 70-year-old woman, was admitted to the facility on 2/6/07 with diagnoses including (per face sheet) rehabilitation, cerebral arterial occlusion with infarction, dysphagia, late effect hemiplegia, hypertension, diabetes mellitus 2, esophageal reflux, generalized pain, depressive disorder, hypothyroidism, hypercholesterolemia and convulsions.

Review of the most current Minimum Data Set (MDS) dated 6/20/07 revealed the resident was assessed with modified independence with cognitive and decision-making skills. She had short-term memory problems, but her long-term memory was intact.

Surveyors read the charts more than we do.

On 8/27/07 at 10:45 a.m. the resident was observed sitting in her room in a large reclining wheelchair, crying and sobbing loudly. The surveyor asked her why she was upset, and the resident stated her brother had passed away the previous week on Thursday (7/23/07) and the funeral was today (8/27/07). The resident stated she was unable to go because her family was unable to find a van large enough to accommodate her wheelchair to transport her to the funeral. The resident stated the funeral was at 2:00 p.m. “today.”

On 8/27/07 at 10:50 a.m. the unit manager was interviewed and asked about the death of the resident’s brother. The unit manager stated she was sure the resident’s brother had not died recently or last week, and that the resident often “gets confused.”

On 8/27/07 at 10:52 a.m. the Social Service Director (SSD) was asked if the resident’s brother had died the week previous. The SSD answered, “No,” and added the resident “often gets confused.”

Can we see where this is going?

Later it was confirmed the resident’s brother had died the week before, on Thursday, 8/23/07. The SSD stated she didn’t know because she just got her “this morning” (Monday). When told the death occurred last week on Thursday, the SSD stated she was working in the facility at that time.

Review of the resident’s record on 8/27/07 revealed there were no social service notes documenting the death of the resident’s brother.

At 10:55 a.m. one of two certified nurse aides (CNAs) who were present during the discussion stated the resident’s sister had told her last week (on Thursday, the day he died), that the resident’s brother had died. The CNA stated, “I didn’t know I was supposed to report it to anyone.”

Oh boy.

Always, ALWAYS report these types of things to the nurse. Even for those residents who are confused and who repeat the same stories every single day. When we report these things, we hand over the issue to those above. Many times our residents’ confusion is an excuse for not taking their words seriously; both aides and nurses tend to disregard resident complaints and stories. In this case the family of the resident also told staff of the death. Perhaps everyone thought someone had reported this? In the end, the resident suffered because she could have and should have been able to attend her sisters funeral. The facility let the ball drop on this.

Lesson: Report EVERYTHING. Even the non medical, non nursing stuff. If you have access to your facilitie’s social worker/case manager, report these things to this person as well as to the nurse. And keep the ball rolling if need be! You are the resident’s advocate.