Documentation & Standard of Care Issues

  1. I am a RN who does medical-legal review for attorneys and my specialty area is LTC. I have worked almost 17 years exclusively in this area as a staff nurse, educ. coordinator, Alzheimer's unit Dir, and DON. I work both sides, plaintiff and defense. If anyone has any questions about these issues, I would love to chat. LTC is very labor intensive and at time an uphill battle.
    I applaud all nurses who choose this area and challenge each of you to show your communities how precious your work is. I originally started out to do education programs (short one and two hour courses) for LTC nurses on documentation, motivating staff to go the extra mile stc, but did not get much interest from DON's. I would like some feedback as to what does interest Directors/staff dev. for presentations.
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  2. 8 Comments

  3. by   Cristina DAllesantro
    hi gloria:

    it is unbelievable that DONS are not more interested in having their staff be skilled at doing appropriate documentation. And yet, I see this attitude myself. I am a corporate nurse for a large LTC corporation. What are some of the problems you have encountered in your experience? I appreciate any tips on how to inservice nurses with regard to this subject. thanks. Cris
  4. by   Gloria Blackmon
    Dear Cristina,
    I see nurse's that do not know what OBRA stands for and have never been taught the guidelines that they are supposed to follow. I see increased confusion about what the care plan interventions are because this has been lumped in with the MDS coordinator's job. I see nurse's that I truly believe contacted the primary physician about changes in the resident but did not document these calls. We see nurses stating they were following the skin care protocol, but in deposition don't know where they got that information from (P$P) or doing things because some other nurse states, that is how/what we usually do.
    Failure to communicate with families, physician's and administration about isssues and changes is very high. Nutrition and decubitus care is also very high. Falls are still a problem, primarily because the nurse's don't take credit in their notes for all of their efforts. Also not communicating with nurse's aides and making sure that they understand what the goals are, especially in areas where there are many aides in which english is not their forst language. In your facilities, what do you see as some of the problems?

    BlackmonRN@aol.com
  5. by   Sandra Egger
    Dear Gloria:
    I have the same concerns about documentation, however, my main concern is with elder abuse by CNA's who are pushed by peers & supervisors to accomplish tasks in an impossible amount of time. I truly believe this is the primary cause of abuse in our LTCF, and possibly in our home care abuse cases. I would appreciate any feedback in this area.
    segger@aristotle.net
  6. by   Gloria Blackmon
    I agree that some of our elder abuse is a direct result of CNA's having way too much work heaped upon them to accomplish. One of the issues that I have constantly been confronted with in educating hospitals in the area of Skilled Nursing is that older people require more time to accomplish tasks. Therefore, SNF's should not be synonomous with less staffing. It is imperative for charge nurses to offer encouragement and praise to their assistants. While the nurses also need support for their hardwork that always looks like they are just setting at the desk. Does your facility offer any wellness breaks or caregiver support classes. This has been accomplished by utilizing the social worker in some facilities and also by having psychologists/social workers from nearby universities to come to facilities on a given day and be availible to staff to vent anger, disillusionment to a third party without fear of retribution. We are really in a crunch in LTC today to figure this scenario out or we will continue to slide towards depair. Has your facility done a survey with cna's to see what would help them have more job satisfaction? Leave off money, because you are looking for things that you could add or change quickly. Also does your facility subscribe to the CNA journal and have that availible in break rooms. It all boils down that we all need to feel valued and appreciated. It is miraculous what can occur when that happens. I have seen a few facilities that looked absolutely depressing from the outside and once I entered, found that even though they still have old crank beds and equipment from a bygone era, no private pay patients, etc...there was little turnover in staff, everyone took pride in the appearance, family members volunteered to help in many ways and the administrator was helping to serve meals. These are the facilities that motivate me to keep at it, but they sought change from the core level and it was able to spread to the staff. I was made aware today that the govt has allocated new funds to a program to increase awareness of elder abuse to healthcare workers, like a train the trainer type program. You are on target!
    Local hospitals (education dept) will often come to your facility for free and provide an hour long program. This would be great to find out (stress reduction, maybe). There is always an issue of not enough time to let staff off the floor for the class, but as you have astutely observed, are the residents receiving quality care when there is staff on the floor. Food for thought.

    Gloria
  7. by   Kristina
    Hi Gloria,
    I am an RN in LTC. I have the same concerns about documentation. I was reviewing charts yesterday, and the charting was very poor. What does it take to get the nurses to chart correctly?
  8. by   Gloria Blackmon
    First, I'll ask you, do your nurses really know what they are supposed to be charting on? Sounds simple, but I feel that at least 40% of the time, nurses aren't sure what is necessary for Medicare documentation, etc.
    I have discovered this in depositions and interviews with the attorney's for defense related cases. I also used to try to refrain from this, but I find that shocking nurses is a great way to get them to chart better. How do you do that? Well, you have someone like myself come tell them about what it is like in court for nurses, use case examples or use your facilities attorney to come and speak to your nurses. I also think that having a simple documentation guideline availible at the desk to remind them about what needs to be documented, how often, etc. is helpful. I know that you should not have to do it but there isn't really an option. As an aside, Docs have little document guidelines that they use also. Educate them as much as possible. Also, it is a vital part of their job description and you may need to remind them that poor documentation will be reflective in their evaluations. Do you have a risk manager in your system? Remind them that when they get done with their entries, if someone was to ask them 3 years from now, what was happening with that resident, would they be able to tell someone adequately in court by their entries. There are some good books availible by nurses on documentation(Patricia Iyler, Tonia Aiken, Sheryl Feutz-Harter, Janet Beckmann). There is a new book that will be out in the spring that will address specific issues in LTC documentation, by Pat Iyler.

    Gloria

    [This message has been edited by Kizomo (edited 10-25-98).]
  9. by   purplesdk
    Gloria,
    I work in a LTC/Alzheimer's unit and we are attempting to implement simpler more efficient Tracking forms for various occurances (behaviors, skin tears, falls, non-emergency/non-urgent situations). Is there a website or do you have any examples of different types of forms that our facility (in Texas) can adapt to our needs. The form we use for falls is an excellent form, but it just can't be used for all kinds of incidents.

    Any help that you may have or information to impart would be helpful.

    Thanks,
    Sheri

    You may email me at purplesdk@door.net.
  10. by   jyoung1950
    How could one present this at their facility - the ideas you listed below. And is there a specific program that you are referring to?

    As a CNA, and speaking on behalf of my CNA co-workers, something like this would be a dream come true at the facility I work at.

    The turnover in aids and nurses here is extremely high.


    Quote from Gloria Blackmon
    I agree that some of our elder abuse is a direct result of CNA's having way too much work heaped upon them to accomplish. One of the issues that I have constantly been confronted with in educating hospitals in the area of Skilled Nursing is that older people require more time to accomplish tasks. Therefore, SNF's should not be synonomous with less staffing. It is imperative for charge nurses to offer encouragement and praise to their assistants. While the nurses also need support for their hardwork that always looks like they are just setting at the desk. Does your facility offer any wellness breaks or caregiver support classes. This has been accomplished by utilizing the social worker in some facilities and also by having psychologists/social workers from nearby universities to come to facilities on a given day and be availible to staff to vent anger, disillusionment to a third party without fear of retribution. We are really in a crunch in LTC today to figure this scenario out or we will continue to slide towards depair. Has your facility done a survey with cna's to see what would help them have more job satisfaction? Leave off money, because you are looking for things that you could add or change quickly. Also does your facility subscribe to the CNA journal and have that availible in break rooms. It all boils down that we all need to feel valued and appreciated. It is miraculous what can occur when that happens. I have seen a few facilities that looked absolutely depressing from the outside and once I entered, found that even though they still have old crank beds and equipment from a bygone era, no private pay patients, etc...there was little turnover in staff, everyone took pride in the appearance, family members volunteered to help in many ways and the administrator was helping to serve meals. These are the facilities that motivate me to keep at it, but they sought change from the core level and it was able to spread to the staff. I was made aware today that the govt has allocated new funds to a program to increase awareness of elder abuse to healthcare workers, like a train the trainer type program. You are on target!
    Local hospitals (education dept) will often come to your facility for free and provide an hour long program. This would be great to find out (stress reduction, maybe). There is always an issue of not enough time to let staff off the floor for the class, but as you have astutely observed, are the residents receiving quality care when there is staff on the floor. Food for thought.

    Gloria

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