Any LTC DONs out there??

peter73 · Nov 18, 2001

Hello all,

I am having a major problem at my facility with CNA documentation, or should I say the lack of it.

I am moving the BM documentaion to the MAR as squaw nurse has done.

Now for the ADL sheets.

Do your facilities use them?

This is the first facility that I have worked that required them.

The nurses do weekly charting in a four week cycle that covers all ADLs and MDS data. Medicare residents are charted on ADL function daily and all reported declines / acutes are charted on daily, I think it is well covered without the CNAs diong ADL books and creating discrepencies. ( we have had residents that have died or discharged that continued to perform ADLs at baseline)

Inservicing did not help, the staff nurses leave me notes that they did not get done when I'm not there. The nurses do not enforce the documntation and I am not there 24/7 to stand over them nor can I review 120 sheets on a daily bases.

I see the ADL sheets as a rope around our necks when survey shows up and would rather not do them than have them done incorrectly or irregularly.

Also our CNA group sheets list care instructions and base ADL data as a mini care plan for CNAs. They sign and turn them in to state they completed the group as planned and required.

I just feel that we are documenting this to death and increasing the chances of error.

peter

OneThunder, BSN, RN · Nov 18, 2001

I know what you mean. I always wanted to make sure there was documentation about a certain issue, but no more than one place. It is a RED FLAG when you have several places to document-and there are discrepancies. And BM documentation was always a trick. I worked several facilities in the area thru agency, and the best way that it worked for me (but then again, the charge nurse had to monitor it) the CNA's would document the BM on the assignment sheet for that shift, and at the end of the shift, the nurse has to transfer that info to the MAR. Most of the nurses put a '0" in at the begining of the shift, and by the end, write over with a S,M, or L if they had a BM. There are very little holes, and if there is, you can back track it by checking that shift's assignment sheet.

As for the ADL documentation-I think it is a potential RED FLAG also. I don't know what the answer would be to that, except for "spot" monitoring, trace back the culprit and counsel. But if you think that is time consuming, check this out. Our corporation had a great idea (LOL). They wanted the CNA's to complete a small 1/4 page paper on each shift and each resident. These were to be mounted in the chart. Supposively this was suppose to cut down on copying the previous shifts documentation. The only thing it did was make our charts HUGE!IT was less than 3 months and multiple complaints from the various facilities when that great idea went down the tubes. (Thank God). If I may be permitted to dream a little here, I always have been playing with the idea of computer CNA documentation. A software program that the CNA answers a few short questions about the resident (how many assists, how much they ate for a meal- easily answered questions) and the program saves the answers and compiles them into a "snap shot" of the residents abilities. Of course it would be MDS based. Oh and it will not let the CNA punch out at the end of the shift unless the questions were answered. This would also provide computer compentencies for the staff. And it doesn't have to be expensive- most facilities have computers now. I see a computer set up at the nurses station called the "documentation station". Remember, it has to be simple questions. Easy to do, it can't take more time than they already spend on documentation. Any software wizards out there?

squaw nurse · Nov 19, 2001

We also have had the problem with CNA's documentation on ADL flow sheets. When I searched the HCFA guidelines for direction on what had to be documented I was surprised to find there is no regulation stating the CNA must document. The only things I found to be required was nursing documentation, and of course you must have a written record of meal consumption and BM's. According to the regs, we must provide ADL's but it does not state routine care must be documented.

So, to solve this problem we did away with CNA documentation. Instead we use a care sheet that describes in detail the care needed for the resident. Just to cover myself legally, I have the assigned CNA initial a sheet daily that states "I have reviewed the care plan and provided the assigned care." I'm not sure what the regulations require in your state, but it is legal in our state and pronto, no more problems with CNA documentation. This allows more time for providing care, saves time for the DON on reviewing the documentation and always fussing because the CNA has not documented. Another advantage is preventing the CNA (though most of my CNA's are great, every facility has one or two of these) sitting in the break room with the ADL book in her lap visiting with her friend and never getting around to charting.

Hope this helps you guys. It has worked well at our facility. The state surveyors frowned on it at first, but could not provide me any regulatory basis for requiring it. Of course we do have task lists on which the CNA reports information to the charge nurse such as recording I&O, BM's, VS, etc, but this is not a part of the permanent record, and therefore reduces the risk of blanks on the ADL sheets which will get you in more hot water.

AGI · Nov 20, 2001

I too hunted for regulations re: ADL documentation, I also talked with our DOH, they agree there are no regs and daily doc doesn't need to be done, but need sometype of follow-through. By dec 1 we will have eliminated the CNA flow sheets, but simplified cp are at CNA station and they will need to know where to look for the info, while doing MDS assessment's today, I absolutely made the decision to do away with the flow sheets. We do have a BM list, dietary intake records so that solves that. i am also having the CNA do a "functional assessment" during the reference period of each MDS. So, eventually everyone will have some type of documentation but not the needless, unusable daily doc.

spudflake · Nov 20, 2001

How much I admire you all. I was a DON for LTC for 2 years and got OUT. Why?? Reimbursement.!! Each state is diferent but it all boils down to $$$. Right now there is no money in LTC. Facilities are closing nation wide. Look at all the bankrupcies. It's disgusting. The State nd Feds have their mandates. I used to just laugh over the OBRA rules and regs and the MDS's are a joke!!! Care plan that the resident prefers to be called Jimmy not Mr. Smith. Give me a break. Because several facilities took advantage of our senior population we are ALL paying. Gone are the days that pts. were tied down. Now they can all fall break a hip and die. There is no respect for our elderly. And relly pitty the poor alz. pt. OMG - what a horible wy to end a life.

My love goes out to all of you who continue to do this work. You are NOT appreciated by your Administrator - but I know what good you try to do. Hugs to you all

AGI · Nov 21, 2001

To the contrary, spudflake......I am very much appreciated by my administrator, guess that is because we both respect each other and our heirarchy starts with the residents, then the front-line care givers , then on down. I have been in LTC for 31 years this past Aug, have been a DON since 1997. Sure, there are days when I want to throw in the towel, but I have learned that the grass ain't greener on the other side. YEs, it is frustrating to do all of that paperwork that only gets seen when the surveyors come in, but you get out of the job what you put into it, sometimes, other times you just "buck" up and do your work, guess that's why it is called "work!" :)

squaw nurse · Nov 21, 2001

Spudflake, I have found that I receive the respect I demand. Not only does my administrator respect me, but he also values me, as I do him and every member of the health care team at our facility.

LTC has gone through many changes during the last few years and yes it is hard work, but never in my nursing career have I felt so rewarded. I have to disagree with you concerning the end of life issues. We must all face end of life issues- some with Alzheimers, some with cancer, and still others with multisystem failure. I consider it a privilege to be able to serve and provide dignity to that special Alzheimer's patient, or to hold the hand of the terminal cancer patient. While most of our patients do not get better and return home, I find it most rewarding to be able to provide some degree of dignity to those who are no longer able to care for themselves.

LTC nurses deal with those special issues such as incontinence and restraints with innovative methods all while preserving the dignity of our residents. Many of us have been able to completely eliminate restraints while decreasing falls and injuries at the same time. It takes an open mind, planning, and lots of patience.

Thankyou for recognizing our hard work and the contribution we make to nursing. Though frustrating, I still love what I do and wouldn't trade places with any other nursing speciality. I've been there and tried several others and always return to LTC where I feel I can make a true contribution.

GreytNurse · Jan 17, 2002

While I 'admire' your responsibility, I have to admit that I don't have much respect for DON/ADON. Sorry, nothing personal, as I don't know any of you, it's just that the one's I have worked for have left a very 'bad taste in my mouth'. I would absolutely LOVE to work under the direction of a DON/ADON that actually helped on the floor when we were short or acted like they really appreciated your dedicated work. Hopefully, one day I'll find that:confused:

As a nurse who just cherishes LTC, even with all the 'ups and downs', I can tell you that if you want your staff to.....show up, not call off, complete their assignments, be happy......you have to 1. show appreciation 2. offer incentives/bonuses.......and not 50 cents an hour!! That only adds up to $4 a day.......I agree, not worth it.

Where I'm at, we have specified # of CNA's on each hall, if we have a call off and they work short on their hall, they all get $4 an hour extra for the shift. You come in and work on a non-scheduled day??? $50 cash (no taxes out) You don't call off or clock in late for a month.....$100 cash. Every 6 months, we have a drawing of all the monthly winners and they get $500 cash. It seems to work, as we rarely have call offs. CNA's work their butts off and without them, we can't do our job as nurses......oh I guess we could, we would need alot more nurses tho.....CNA's deserve to be paid atleast $10 hr and more.......actually I say more. LPN's pay is pretty sick too.......they should start out at $15 and prorated to time and experience. No wonder facilities are always short and in need of staff. One reason why agency seems to be a good choice now days.....more money. That is what it boils down too.......$$$$$$$$$$$$$ Our population of elderly is growing daily and we are in desperate need of new facilities to care for them, but we have no staffing! I just hope I die before my kids have to place me in LTC......... :rolleyes:

night owl · Jan 20, 2002

GreytNurse,

Thank you for speaking up for us staffers and by the way, can I come and work at your facility? Those incentives sound pretty good to me! I'm an LPN with 25 years experience...

jschut, BSN, RN · Feb 5, 2002

I'm not a nurse yet, but I do work in LTC. Our DON has spent numerous hours at the facility, taking up the slack from folks who don't come in. She has been called in on 3rd shift (middle of the night) and come in to help. She is an amazing and kind nurse, one who I admire and pray I have her enthusiasm when I graduate.

I admire all of you who work in LTC. It's an overwhelming and under appreciated job most of the time, and to those of you who make life worth while for the elderly, I just want to say "May God richly bless you always."

Hugs to all~

Julie:)

Sleepyeyes · Feb 17, 2002

I've been reading your posts with interest, hoping to learn more. Could you please tell me how you chose to be DON in the first place? Was a BSN required? which specialized skills? Should I get accredited as a Geriatric RN or is there some way for me to get credit for work experience? For those of you who truly back up the staff(((((HUGS)))))

You can email me if you prefer not to take up space here.

Thanks for letting me butt in....

GreytNurse · Feb 18, 2002

:zzzzz Sleepyeyes......you really don't need any 'specialized' training. You must, however, know the state regs for LTC. Most of the DON's I know started out as ADON's and some were even hired without any prior knowledge at all........learn as you go stuff.

Most DON positions are held by RN's.......diploma,ADN,BSN.....doesn't matter to most. Some DON positions are held by LPN's as well. Alot of LPN's hold ADON positions. With the high demand and nursing shortage rampant, especially in LTC, some plaves will take just about anybody.

Good luck. It can be the most stressful job, the most thankLESS job you have, but the most rewarding!!

There are programs for LTC certification for LPN's. Not sure about the RN's.