Dementia Activity Documentation for CNAs

canigraduate · Oct 28, 2011

This is all very nice in theory, but if your CNAs are as overworked as is the norm, then you are going to get a lot of make-believe charting.

Perhaps it would be better to do a time study first to see if this change is feasible. When I was a CNA in an LTC, I would never have had time to do these extra things, much less chart them. I was lucky to keep everyone clean and get their teeth brushed three times a week.

You may want to run this by some of your senior CNAs, also. They will be happy to tell you if it's something they are able to add to their workload or not, and why.

m.k.a.u. · Oct 28, 2011

This is all very nice in theory, but if your CNAs are as overworked as is the norm, then you are going to get a lot of make-believe charting.
Perhaps it would be better to do a time study first to see if this change is feasible. When I was a CNA in an LTC, I would never have had time to do these extra things, much less chart them. I was lucky to keep everyone clean and get their teeth brushed three times a week.
You may want to run this by some of your senior CNAs, also. They will be happy to tell you if it's something they are able to add to their workload or not, and why.

Hi,

I have been working in our skilled nursing facility/LTC for a few years as well and I know that our CNAs are seriously overworked. But in our dementia care unit, I see them stand around and have chats since it is only a 15-bed locked unit. And I did speak to the LVN supervisor to ask whether the documentation is possible. That is where I got the suggestion of using a checklist form so that they are not spending time writing down a summary. Which I thought was a good idea since illegible handwriting would pose as a problem. I also ran this by the executive director, but have not yet run it by the health services director. I would be using this documentation as an accountability form to evaluate whether the CNAs are working towards our new unit goals/philosophy and it will serve as an update for me as well on each resident during our resident reviews.

canigraduate · Oct 28, 2011

Hi,
I have been working in our skilled nursing facility/LTC for a few years as well and I know that our CNAs are seriously overworked. But in our dementia care unit, I see them stand around and have chats since it is only a 15-bed locked unit. And I did speak to the LVN supervisor to ask whether the documentation is possible. That is where I got the suggestion of using a checklist form so that they are not spending time writing down a summary. Which I thought was a good idea since illegible handwriting would pose as a problem. I also ran this by the executive director, but have not yet run it by the health services director. I would be using this documentation as an accountability form to evaluate whether the CNAs are working towards our new unit goals/philosophy and it will serve as an update for me as well on each resident during our resident reviews.

Thanks for clarifying. I agree that your goals are admirable and patient-centered. I just question your perception of the CNAs availability.

Do you mind telling me how many CNAs are assigned to the unit? Also, when you say chatting, what do you mean in terms of length of time and content? The reason I ask is that I was talking to a resident's relative once where my shift supervisor could see and I got blessed out for 10 minutes for talking instead of working. It took longer for the reaming than the conversation.

I don't think it's unreasonable for CNAs to chat for a few minutes here and there throughout the day. Just think of how many times management members stop and talk to each other.

If they are standing in the hall holding 10 minute conversations about topics that aren't work-related, though, that's a different story. In that case, go for it. I would check behind them, though, and make sure they are actually doing their jobs, because they probably aren't. Unless you have 3 CNAs or more on the unit, they shouldn't have that much time if they are doing everything they should.

AJ_427 · Oct 28, 2011

I know exactly what you mean. I work at a facility for the disabled and we have to fill out the activity books.

The way they are put together at my facility is:

- It's a binder that is divided by residents

- First page tells you something about the resident (mobile, can feed themselves, likes to listen to music, etc.)

- Then there are goals. One goal per sheet. It states the resident's and case manager's names. The goal is stated. Under the goal, a detailed description is written of how the goal is to be performed (hand over assistance, verbal prompting, gestures, etc.). Then a long checklist is put. The first row states the days of the month, then there are two rows for the morning and afternoon shift. Each aide has to check plus for residents doing the goal and minus for not. Aides have to initial.

As an aide, all I can write is they can be a pain to deal with. If we know that the resident can't or won't do the activity then we don't even try. If we know that a resident can do a particular goal then we just put plus. Those aides who have worked at a facility for a long time will do this most often. New aides do goals because they want to get to know the residents.

If I was not as busy as I am when we are suppose to do the goals then I would be more than happy to do them. But the reality is that I sometimes have to look after 22 residents with no partner and I just can't do it. But if the aides at your facility don't seem that busy then why not?

Kitsey · Oct 29, 2011

I am a part time 'float' CNA, but I work most often in the dementia unit of my facility. I would love to do things the 'right' way, but there is just no way it's going to happen. We're always short, and next month we are going to be even more short. (It's so bad our facility is now offering a $600 sign on bonus). There is no way I would ever have the time to break down brushing teeth into simple steps. We're lucky if we have time to do a quick swab with mouthwash. Sad to say most get no oral care whatsoever. I feel horrible about this, and would never want my family treated this way, but it's all about $$$. They don't want to staff enough of us to do a good job. And I'm speaking as someone who almost never takes any of her breaks. Having more charting checklists to do would just make my job more stressful, and take more time :/

m.k.a.u. · Oct 29, 2011

Thanks for clarifying. I agree that your goals are admirable and patient-centered. I just question your perception of the CNAs availability.
Do you mind telling me how many CNAs are assigned to the unit? Also, when you say chatting, what do you mean in terms of length of time and content? The reason I ask is that I was talking to a resident's relative once where my shift supervisor could see and I got blessed out for 10 minutes for talking instead of working. It took longer for the reaming than the conversation.
I don't think it's unreasonable for CNAs to chat for a few minutes here and there throughout the day. Just think of how many times management members stop and talk to each other.
If they are standing in the hall holding 10 minute conversations about topics that aren't work-related, though, that's a different story. In that case, go for it. I would check behind them, though, and make sure they are actually doing their jobs, because they probably aren't. Unless you have 3 CNAs or more on the unit, they shouldn't have that much time if they are doing everything they should.

Hi canigraduate,

They chat in the office and sort of lazily walk around. Their attitude sucks and their work ethics are nonexistent. This is one of my reasons for wanting to implement some sort of documentation. There are teo CNAs with a float making it three fr a 15 bed unit. And this is a dementia unit so there arecertain qualifications that the residents must meet in order to stay there. These residents do not need a very high level of care like the residents I worked with in SNF. therefore, I know these CNAs do not have to work as much as that unit. But because of their laziness, I need to implement a documentation form so that they have some sort of accountability.

m.k.a.u. · Oct 29, 2011

I know exactly what you mean. I work at a facility for the disabled and we have to fill out the activity books.
The way they are put together at my facility is:
- It's a binder that is divided by residents
- First page tells you something about the resident (mobile, can feed themselves, likes to listen to music, etc.)
- Then there are goals. One goal per sheet. It states the resident's and case manager's names. The goal is stated. Under the goal, a detailed description is written of how the goal is to be performed (hand over assistance, verbal prompting, gestures, etc.). Then a long checklist is put. The first row states the days of the month, then there are two rows for the morning and afternoon shift. Each aide has to check plus for residents doing the goal and minus for not. Aides have to initial.
As an aide, all I can write is they can be a pain to deal with. If we know that the resident can't or won't do the activity then we don't even try. If we know that a resident can do a particular goal then we just put plus. Those aides who have worked at a facility for a long time will do this most often. New aides do goals because they want to get to know the residents.
If I was not as busy as I am when we are suppose to do the goals then I would be more than happy to do them. But the reality is that I sometimes have to look after 22 residents with no partner and I just can't do it. But if the aides at your facility don't seem that busy then why not?

Hi AJ,

I will be putting together a separate activity chart binder for each resident much like what you are describing. Except I will be the one to manage it and I want to keep the CNAs from doing extensive charting like what you have to do. I want to make a checklist form so that there isn't a lot of writing going on and they will not be doing daily activity charting either. I will take care of that since I will be the one facilitating the majority of activities. What I would like the CNAs to do is understand that the activities of daily living they help the residents with is also considered an activity but they can take it one step further and bring value to that interaction. In that I mean help them learn the steps that is required in brushingtheir teeth, etting dressed, etc. It is like training them to become more independent. That's what will make that interaction more meaningful. And since the administration wants the CNAs to be more involved in activities, the CNAs should have more one on one time with them either reading books or helping them with puzzles, etc. Either way, they should at least have the goal of doing one meaningful activity with each if their residents. This is not about whether they have time for this or not. This will happen because the administration is making it a requirement. I am just figuring out a way to put it in paper form as a record. But one thing is for sure, I do not want them doing all that documenting the way you are. It just isn't possible for them to be able to do all that. It's time consuming and taking them away from resident care.

m.k.a.u. · Oct 29, 2011

I am a part time 'float' CNA, but I work most often in the dementia unit of my facility. I would love to do things the 'right' way, but there is just no way it's going to happen. We're always short, and next month we are going to be even more short. (It's so bad our facility is now offering a $600 sign on bonus). There is no way I would ever have the time to break down brushing teeth into simple steps. We're lucky if we have time to do a quick swab with mouthwash. Sad to say most get no oral care whatsoever. I feel horrible about this, and would never want my family treated this way, but it's all about $$$. They don't want to staff enough of us to do a good job. And I'm speaking as someone who almost never takes any of her breaks. Having more charting checklists to do would just make my job more stressful, and take more time :/

Hi Kitsey,

Unfortunately that's true. I did consider the possibility of an extra charting task to be excessive. But in order to teach the CNAs responsibility and ensure they provide quality care, they will need to document. With such a small unit, the CNAs should have enough time to do so an I am making a checklist quick and simple enough so that it doesn't take too much time. Plus, I spoke to the higher ups ad they agree with it. And the LVN supervisor said as long as it is simple and doesn't require a lot of time, then it is possible.

m.k.a.u. · Oct 29, 2011

Hi,

I am getting a lot replies about how it may not be possible to add another form of documentation to a CNA's job duty, but let's say that it will be implemented regardless. Whether or not they will have time is not the matter in question. Also, I have seen the CNAs in action in that unit and I know try have the time to do so. My real question is how should I write up the documentation. It will be a checklist form for simplicity and efficiency. I just don't know what exactly to put on the form.

Thanks all.

CompleteUnknown · Oct 30, 2011

Hi m.k.a.u, I've been wondering whether or not to reply to this as perhaps I'm not understanding what you're driving at. I know you said the form is being introduced anyway, but here are my thoughts. :)

I too think your goals are wonderful, but would say they are what everyone should be doing anyway. For your example with teeth cleaning, if it's been decided that staff should give step by step instructions for cleaning teeth to a particular resident (take cap off toothpaste, put paste on brush, etc), shouldn't this already be on the care plan, in detail, as an intervention? Same with choosing clothing; for those residents who can still manage this with some prompts, this should be on the care plan too. If it's a resident who becomes overwhelmed by a lot of choices, the care plan should say 'offer choice of two shirts' or however you want to word it, as part of the interventions.

If this sort of thing is already on your care plans and the staff know how they should be doing these things, I'm not sure that you will achieve much by introducing more documentation. If it's not getting done (and assuming there is enough time) I'd be more inclined to think the staff need education on the benefits to the resident of this approach (such as happier residents, decrease in challenging behaviours, maintaining function for longer, etc), and on culture change in general.

I've worked in facilities where I've had to spend huge amounts of time and effort to change the way staff think about what they are doing, it's hard work but it's certainly possible and it really does improve things for everyone.

If that's not the case, and the staff already know what sort of approach you want but it isn't getting done, I think I'd first look at why. If it's a lack of time, a new form is not your answer. If it's a lack of knowledge or a belief that it won't do any good or a general lack of understanding on the 'whys' of this, a new form is not your answer either (in my opinion), change the thinking first and then you'll either have no need of the form, or will be able to introduce it with everyone understanding the reason for it and truly being able to think about why it's being filled in and thus able to suggest changes in approach when the current interventions are not working, need changing or are no longer appropriate.

What about something like a daily or weekly brief 'team meeting' (doesn't have to be formal, just a hallway get-together type of thing) and talk about it. "How is Mrs Jones going with cleaning her teeth? Is everyone giving step by step instructions? Is it working? Have you seen any changes? etc etc). I still think your goals like fostering independence, maintain function, improve self esteem, increase emotional well-being, etc should be on the care plan with the way to achieve this written as individual interventions that will be different for each resident. And of course, the care plans should be easily available for everyone to look at.

I guess if you're going to introduce the form anyway, I would take the headings from the care plan or just write down what you want eg 'resident maintaining independence with dressing with step by step instructions from staff' and then a yes/no tick box. Or perhaps a heading could be 'dressing' and the choices could be 'requires staff to perform all tasks', 'resident able to follow some simple instructions', 'resident can dress self with step by step instructions'. It all seems like a LOT of work for you in developing the form and for the staff in filling it out every shift, and this is only for the physical task-type things. I find it hard to imagine how you would do it for things like value and meaningfulness - you're asking staff to make a very subjective assessment there. I wonder if you can use existing forms like behaviour charts to capture things like resident response and resident participation.

CraftyStarr · Nov 2, 2011

m.k.a.u.-

You may totally take this the wrong way, but...

It sounds to me like what you are dealing with is a management problem that a form isn't going to fix. You state that your CNAs are lazy and that your administrators and director want to change the culture of the organization. It seems to me that creating more work and new forms isn't going to change a culture.

If it were me and I was managing a new staff and I wanted to implement a culture shift I would start by talking to my staff. You state that you spoke to the "higher ups", but have you spoken directly with the staff that this is going to affect? I feel like there is some important information that could be gathered from them. Do some of them already try to implement the sort of interventions that you would like for them to? What sort of information do they think would be good to have on the form? Why do they think it is OK to stand around in the hallways for significant periods of time? Are they able to identify "teachable moments" with your residents? In my experience, the only way to get people to use new forms effectively is to have their buy in. The only way to get their buy in is to involve them in the process so that they can have input. If people feel like a form is a waste of time, either they are not going to fill it out or they are simply going to make the information up. If the forms aren't going to be used properly, why waste your time?

By having these conversations with your new staff, it will give you the opportunity to get to know them. As their manager, you are supposed to be their greatest advocate. I get the impression from your posts that you don't have a lot of respect for them. It's awfully hard to advocate for people you don't respect and/or like. Meeting with them to talk about this issue might give you a new perspective about who they are and what their issues at work are. Working on this project with them will give you the opportunity to start building trust. Loyal employees can make your job really easy, but if they don't trust you they can make your job horribly difficult. On the more management-y side, if you document the process and document your staff's involvement (or lack of involvement) it makes things easier if you need to terminate employees later.

I hope that I haven't come across as too condescending. That isn't my intention at all. It sounds like you are a new manager that is excited to do a great job and I think that's wonderful! It also sounds like you are sitting on the same side of the table as administration, when (in my experience) you should be sitting in between administration and staff. You need to implement the changes administration dictates, but you also need to let administration know when their expectations are out-of-line. A good relationship with your staff is essential to walking this line. It sounds like you are getting ready to "crack down" on your staff, and by doing so in such a dictatorial way, you may be setting yourself up for some pretty rough head aches in the future.

Again, I am sorry if this rubbed you the wrong way...I don't mean to offend!

Kim