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.