Archive for the 'Observation, Reporting and Documentation' Category

Provider Magazine, a long term care trade publication, has an excellent article up about how CNA documenting can be streamlined and made much more efficient and, productive. In less time.

Read on (PDF File)

A new pressure ulcer reduction program—known as On-Time Quality Improvement for Long Term Care(On-Time)—was developed by the Agency for Health Care Research and Quality (AHRQ) with support from the California Health Care Foundation in an effort to close the gap between staff knowledge and staff practice.
[...]
Since certified nurse assistants (CNAs) spend the most time with residents, they are frequently the first to notice subtle health status changes; however, their observations often never reach the team members who are formulating care plans. In addition, nurses are sometimes reluctant to use CNA
documentation because it may not accurately reflect resident health status and is often incomplete.

More:

There are three key components of the On-Time program:
*Assessing current CNA documentation, streamlining CNA documentation, incorporating best practice elements into daily charting, and consolidating CNA documentation into one form;

*Establishing audit and feedback processes to confirm CNA information completeness and accuracy;

*Integrating weekly reports that identify at-risk residents into care planning processes and structures.

Sometimes I wonder about ALL the documenting we do- is it helpful, is it really necessary and, who reads it? Where does it all go? AND how much of the paperwork is geared towards making someone’s else’s job easier? Hmm.

Implementing The Program
Successful implementation of the On- Time model entails the following three steps.
Step One: Streamline and standardize CNA documentation to capture relevant information. The heart of the On-Time program lies in the daily care documentation conducted by CNAs. Prototypes of the CNA documentation form and the On-Time reports are the starting point for implementing the program.
During the first stage of the initiative, documentation forms currently used by CNAs are reviewed; cross-referenced against regulatory requirements, facility care protocols, and best practice elements; and compared to the On-Time CNA form prototype.
[...]
The result of this process is the development of a new CNA form designed to include best practice elements and to eliminate both redundancy and documentation of unessential items.

READ the entire article HERE; this is a PDF file and it’s very worth printing and saving. Any efforts to reduce the amounts of paperwork is worth looking into. CNA’s and nurses spend astronomical amounts of time writing, checking, noting and reading many forms, sheets, records, logs..much of it is inefficient and wasteful.

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.

An interesting article about dysphagia screening and assessment, and the various professions roles in this process:

Hospitals that are credentialed as stroke centers must have a screening tool for dysphagia in place, according to the American Heart Association. Furthermore, the Joint Commission states that a screen for dysphagia should be administered to patients with stroke before they are given “food, fluids and medications by mouth.”1

In compliance with these requirements, some hospitals are introducing a swallow screening procedure designed specifically for nurses. The purpose of the procedure is to enable them to screen newly admitted patients who may be at risk for aspiration and quickly determine if they are safe for oral intake.

And:

It’s important to note that the nurses who perform the screening are not performing swallow evaluations, nor are they replacing speech-language pathologists.

“My job is to perform a comprehensive evaluation on every patient. This [procedure] allows nurses to more accurately determine who needs a full evaluation and who can start their oral intake. An evaluation is far greater than that,” said Audrey Cohen, MS, CCC-SLP, of the Department of Speech, Language and Swallowing at Massachusetts General Hospital (MGH)in Boston.

Training the nurses:

Staff can access a Web-based training module via CD or the hospital Intranet. The module includes background information on the nature of dysphagia, aspiration and oral hygiene. It also differentiates between a swallow screen and a comprehensive evaluation and explains the role of the nurse in caring for patients with dysphagia.

The training module shows a demonstration of how to perform the screening appropriately, with video clips of patients exhibiting normal and abnormal responses. As part of their training, nurses must perform the screening at least five times under the supervision of a speech-language pathologist.

Where CNA’s come into this:

If a swallow evaluation is warranted by an RN, nurse practitioner or physician, the speech-language pathologist establishes the patient’s safest diet level and discusses safe swallowing techniques with nursing. All of the information is placed on a swallowing instruction sheet in a Communication Binder that the departments pass back and forth.

“We write down the patient’s diet level and any safe swallowing strategies that we feel need to be implemented with the patient during the meal,” said Repsher.

In each dining room a trained certified nursing assistant (CNA) is assigned to a supervision table and uses the information on the swallowing instruction sheet to ensure the patients eat safely. The CNA adds specific comments, such as if patients are having difficulty during the meal.

The facility offers dysphagia groups for patients. Speech-language pathologists instruct patients on compensatory strategies and safe swallowing techniques. They assess the safety of the patient’s swallow and increase the diet level as tolerated.

When appropriate, the nursing staff is given a demonstration on how to carry out these instructions.

“We show them what the patient needs to do,” said Repsher. “If the nursing assistant is in the dining room at the same time that we’re at the supervision table, we would instruct the nursing assistant on the strategies the patient needs to use.”

This information is then included in the Communication Binder.

CNA’s are on the forefront of dysphagia. We see it, hear it, watch it happen when we witness coughing, choking, strained swallowing, pocketing of food, slow or incomplete swallows. Our observations are critical to the entire process. It’s very important to share these observations with the nurses or SLP when they ask. Episodes of difficult swallowing or choking must be reported and potential illnesses watched for. The CNA is the vital link in this.

Nursing homes should have a similar plan in place for these issues. “Resident Oral Intake” Guidelines should be set up for each resident who eats.

Nursing Home Magazine does it again: AN excellent article about dysphagia and swallowing problems, some of which is aimed at CNA’s:

Dysphagia is not unusual among older adults living in long-term care facilities. One study recorded the presence of mealtime difficulties in nursing home residents and found that nearly 90% had impairments that included dysphagia, poor oral intake, positioning problems, or challenging behaviors. Furthermore, 68% of the residents experienced dysphagia, compromising their ability to enjoy meals, let alone consume the necessary calories to meet nutritional requirements. Dysphagia can lead to aspiration, choking, dehydration, malnutrition, and pneumonia. In fact, aspiration pneumonia is the fifth leading cause of death in people over 60 years of age and the third leading cause of death in people over 80. Clearly, food intake is crucial to many residents’ health and quality of life.

Residents with dysphagia often require modified diet consistencies, such as thickened liquids or pureed foods. In addition, nursing assistants must often comply with specialized feeding techniques, such as placing food in the non-impaired side of the mouth, limiting the use of straws, or facilitating the use of adaptive feeding equipment. In the dining room, nursing assistants who provide help to, monitor, or feed residents must follow the techniques for the residents’ safety and nutritional health. Failure to successfully comply with swallowing and feeding recommendations can cause inadequate hydration and nutrition and unsafe feeding.

More:

Through therapy, a speech-language pathologist can help many residents with dysphagia learn compensatory swallowing techniques. Researchers have found that poor staff training and a lack of understanding about feeding recommendations can cause malnutrition and dehydration in long-term care. McGillivray and Marland conducted a review of the literature on assisting people with dementia during meals. Their review found that mealtime assistance is often stressful for residents and staff because feeding becomes task centered and staff have not been sufficiently educated or trained.

I think ALL staff could use more training.

Did you know?

Signs and Symptoms of Dysphagia
Some signs and symptoms of dysphagia are not commonly known. For example, did you know that a persistent low-grade fever might be a sign of dysphagia? Did you know that if a resident is spitting food at meals, he or she might have oral phase dysphagia and might be unable to chew properly? Review the list below with your staff. Residents displaying the following signs and symptoms of dysphagia should be seen by a speech-language pathologist:

* Having trouble recognizing food
* Difficulty placing food in mouth
* Drooling or spitting
* Food falling out of mouth
* Pocketing of food in mouth
* Rocking tongue back and forth while chewing
* Food left in mouth after the swallow
* Chewing for a long time
* Coughing before, during, or after the swallow
* Delayed or absent rise of the larynx during the swallow
* Requiring 3–4 swallows after each bite
* Continuous throat clearing during or after the meal
* Wet or hoarse voice
* Complaining of something caught in throat
* Refusing to eat or very slow eater
* Lasting low-grade fever
* Unplanned weight loss or unexplained loss of appetite
* Pneumonia
* Malnutrition or dehydration

This article provides an excellent review of swallowing problems for nursing home residents and would be a timely and good resource for an in service.

A reminder of some of the materials here, that can be used without charge, for CNA educational purposes or for inserivces.

Horizontal Violence

A Call For Action

Being Professional: Guide For CNA’s

CNA’s & Respect

Workplace Culture: CNA’s can make it or break it

Shift Wars

Tips & Timesavers For CNA’s

Legal Issues For CNA’s

The Nursing Process & CNA’s

Observation Skills For CNA’s

Continuing Ed For CNA’s: Just Another Inservice?

Email us for a TEXT or WORD version of these materials.

In the near future we have several more posts that will be up for grabs:

Falls: The CNA’s Role in Assessment and Prevention

Mentoring: A SKILL for CNA’s

An aide is in major trouble for giving residents a bath in water that is TOO HOT.

Paula Marie Drew, 40, was charged on Wednesday with two counts of caretaker neglect for two incidents at the Green Park Nursing & Rehab Center, where she worked before she was suspended March 1.

According to an affidavit filed with the charge, Drew gave showers on March 1 to two residents who later were found to have been scalded.

When Drew placed the first resident in the shower, he suffered a seizure, fell, and hit his head, states the affidavit by Steven Johnson, a criminal investigator with Attorney General Drew Edmondson’s office.

Drew summoned a nurse to the shower room, and the nurse found burns and peeling skin on the man’s face, neck, stomach and thighs, the affidavit says.

The resident, who was blind and mentally retarded, was hospitalized with burns over 20 percent of his body and a head injury, according to court records.

The next day, a second patient at Green Park developed large blisters on his hand and arm, the affidavit says. Drew also had given a shower to that resident March 1, the affidavit says. That patient, who was mentally retarded, was hospitalized with burns over 6 percent of his body.

The day after the scaldings, a state Health Department nurse checked the facility’s water temperature and found that it was 126 degrees, nine degrees higher than allowed by state regulations.

Drew told investigators that “she did not intentionally burn” the residents but “did admit that she left both residents alone in the shower too long for an unknown length of time,” the affidavit states.

Often the nursing home also must take responsibility for these types of injury. More and more though, aides are being held personally accountable because they can and should KNOW when water is TOO HOT…they should always seek supervision when in doubt about this stuff. It matters little that the residents were left unattended in the specifics of bathing (although this is another crime altogether); what matters is hot water burns on contact.

Where I work we have water thermometers located in each tub area as well as where every shower is located. LNA’s are expected to measure water temp before placing a patient in the water. Any temp over 104 means TOO HOT= NO BATH/SHOWER. We get the nurse and document this and call maintenance. We have these safeguards in place precisely to prevent burns.

Here’s a reason why residents who wander, can end up dying outside on a cold night.

MARION, Ind. (AP) Indiana regulators say the staff of a Marion nursing home failed to look in on an Alzheimer’s patient the night he wandered outside and froze to death.

Staffers at Bradner Village Health Care found the body of 76-year-old Clarence Elliott at about 3 a.m. on February 15 outside a locked door of the home. Temperatures fell below zero that night.

State regulators found that staff did not check Elliot’s bedroom at 10 p.m. or midnight on the night he died. The department also determined that Bradner did not notify Elliott’s family or his primary physicians of his death.

A Bradner administrator says corrections have been made, including firing two employees. The U.S. Centers for Medicare and Medicaid Services will determine whether the home should be fined.

HEAD COUNTS. Real ones. Where you actually go into the residents rooms and check their beds…and feel for a human being under the covers. And on bitter cold nights…more often than once every couple hours. A human being will die in less than 15 minutes being out in that cold.

When a resident or patient falls, and hits their head, nursing staff have serious responsibility to monitor the possible effects. Brain injuries are life altering events and sometimes we can prevent this from happening. By intervening at critical times, we have a big impact on people.

Nursing Home Magazine’s October Issue has guild lines that are sound and should be followed. CNA’s often play an important role in helping the nurse perform neurological exams. It’s vitally important to be timely when you’re asked to help with these exams. The best scenario would be for the nurse and CNA to go together to do this.

Protecting Your Residents and Facility
A crisis of the neurological system can be the most challenging to monitor and evaluate for any healthcare professional. Whether it’s a brief check of neurological status or a comprehensive neuro exam, a nurse’s assessment may uncover nervous system dysfunction before it is too late. Therefore, it is essential that every nursing facility has policies and procedures, coordinated by the medical director, to guide and address when and how these exams should be done. Consider the following when developing your plans:

1. Have a licensed nurse perform neurological checks after all unwitnessed falls involving residents with a history of confusion or residents with a suspected head injury.

2. Check for signs and symptoms of head injury, which include one or more of the following:

* unusual drowsiness or can’t be awakened (easily or at all), mental confusion, slurred speech
* nausea and forceful or repeated vomiting, stiff neck and fever
* seizure activity
* unequal pupils, papillary response, or accommodation
* clumsy walking, stumbling, or other problems with use of extremities, areas of numbness, parasthesias
* headache (mild or severe), dizziness, double vision, or blind spots
* increased blood pressure or a marked drop in blood pressure
* decrease in pulse and/or increased and shallow respirations (these are associated with intracranial pressure)
* unequal grasp and/or nonexistent extremity movement (these are associated with cerebral damage)

Right here is where CNA’s are often called upon to assist with these exams. We’re the ones who will first encounter residents and patients who:
*Cannot be aroused as usual or who seem more tired than normal
*Have a fever
*Respirations that are different- slow and deep or fast and shallow
*Complain of a headache
*Vomit
*Experience dizzy spells or complain of double vision
*have a change in their normal B/P readings
*Cannot hold onto things they normally can- dropping a hairbrush or comb, for example
THESE observations should be reported the nurse immediately. Not in an hour. Not after care is given.

3. Conduct an initial thorough exam at the location where the resident was found, without moving him or her. Wear gloves when necessary and provide as much privacy as possible.

4. Evaluate the level of consciousness and mentation of the resident. A change is usually the first clue to a deteriorating condition. Since terms, such as lethargy, are frequently used imprecisely, it is wise to descriptively document how the resi-dent responds.

5. Check pupil reaction, blood pressure, temperature, pulse, respirations, grasp, and active range of motion of all extremities. If neck or spinal injury is suspected, keep the resident still and call for emergency help.

6. Obtain orthostatic blood pressures per facility protocol. Move the resident to his or her bed only after a full assessment of injuries or potential injuries is complete, and use a method that will protect the resident from any further injury.

7. Perform neurological checks according to the frequency indicated on the medical director’s or attending physician’s orders. In addition, subsequent assessments should be problem-focused, zeroing in on the parts of the nervous system affected by the resident’s condition. The resident’s diagnosis and the acuity of his or her condition will determine how extensive your problem-focused assessments will be and if you should conduct them more frequently.

8. Be sure to compare your findings with those of previous exams. Through comparison, you’ll be able to spot changes and trends and, when necessary, intervene quickly and appropriately.

9. Immediately notify the resident’s physician of any sign of deterioration in the resident’s status.

Initally after a fall, the resident/patient should not be moved by the CNA. Get the nurse. I have worked with nurses who will refuse to come right down to assess the situation- they’re in the middle of a med pass or something. This is not acceptable. If this happens go to the next person in the chain of command. If no such person is in house, inform the nurse that you will not move the resident/patient until an assessment is completed. And go stay with your resident/patient.

Learn what a full neuro exam is and what tools are needed, in case you’re asked to get them together. Every facility should have a kit with these items all ready for use and clearly labeled.

More about neuro checks:
Neurological assessment: A refresher
The Precise Neurological Exam (pictures included)

Modern technology makes it way into nursing homes.

MOTT, N.D. – Palm Pilots are replacing charts at a nursing home here.

It’s one of five Good Samaritan Nursing Homes across the country to convert to Palm Pilots, which are about the size of a calculator. They’re programmed with each patient’s name and the care that’s required.

The 28 certified nursing assistants at the Mott nursing home use a small pencil-like stylus to tap the screen. At the end of each shift, the entries are transferred to the main computer system so the shift nurse can see what’s been done and what’s needed.

Administrator Bruce Kallis said the nursing home started using the Palm Pilots in January, after the staff went through training.

The nursing home company has a four-year grant to pay for the devices.

Erica Jahner, an activity aide, said she likes using hers. She said it makes the time go faster and lets her spend more time with the residents.

“I like it because you can hold it and chart while you’re talking with a resident instead of having all that paper and stuff,” she said.

I bet this was a hard concept to sell to the staff. I can see my workplace going into an uproar at first over this. But I can also it being a great thing.