kardex

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I am a new DON in a critical access hospital that has 20 extended swing patients (nursing home type patients) who reside here. My specialty is ER and I have no experience with LTC so am looking for advice from you experts.

A longstanding problem at this facility has been getting the nurses to keep their care plans for the extended swing patients up-to-date...... and obviously they are not using them to plan and deliver care. I think one step toward changing the culture to one in which they use care plans in their daily work (and base their documentation on them) is to give their shift reports utilizing the resident's problem list. We don't have electronic records yet so I wonder about devising a kardex that includes the patient's problem list which is used to communicate and give report with? Any one do that in your ltc facility? If anyone has such a kardex could I see what yours looks like?

Any other suggestions for getting staff to plan and deliver care based on care plans? Would it be beneficial to buy the premade care plans on a disc that staff could individualize to the patient, print out and put on the chart?

thank you

Afteralltheseyears

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Do they have time to do that?

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Good question. Like I mentioned, there are 19-20 residents. They are cared for by 1 LPN and 2 CNAs. What is a good ratio of nurse to patients that will allow adequate time to do care planning and documentation that is reflective of the care plans? The nurses don't appear to be terribly rushed to provide nursing care (pass meds, carry out treatments, etc) but maybe it's not enough time to write and update care plans?

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I've looked at this a few times and think perhaps I'm not understanding your question, I'm not sure what you mean by give report using the resident's problem list.

What sort of care plans are you using now? The care plans used in nursing homes are usually very lengthy and with the best will in the world you wouldn't be able to read through/update 20 of them at the beginning of the shift, or even during the shift, unless that was all you were doing. How many of these nursing home type patients is each nurse looking after?

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Sorry, I'm not explaining my thoughts well.

The care plans in use now are ones that have been "copied and pasted" from a care plan template. I don't think they are very meaningfully personalized for many patients.

Each of our LPNs is assigned the task of keeping 4-5 of the resident's care plans up to date. They also all know if they are on duty and a different resident (one not on their case load) develops a new problem (for instance, a uti) they need to write a plan of care for that new problem. Not only are they not keeping their assigned patients care plans up to date they also aren't writing new care plans when any resident develops a new problem while they are on duty. If someone looks at the care plans of the residents in our facility they often don't reflect the current state of the resident very well. The nurses notes don't reflect the care plans (or report on new issues with the resident) either. All these were complaints of state surveryors on the last survey. They squeaked by and passed the survey but I know I need to do something to improve their use of care plans as they deliver care and as they document that care. I have a feeling education is a necessary piece of this fix (the LPNs seem to not know how to base care on a care plan) but the tools I'm accustomed to using to communicate (the kardex and shift report) I feel need improvements too. For some time now they haven't used kardexes at all and the shift report is so informal I hear much information doesn't get passed on from shift to shift. So now I'm the DON who sees these issues, must come up with a fix and isn't sure where to start.

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Aha okay, it sounds like some documentation education would be a good idea.

Is it in the LPN scope of practice to develop new care plans? Where I am, it generally must be the RN. Can you update or re-write a couple of the care plans to show how you want them done?

As for the shift reports, and things not getting passed on, what about a sort of large diary or blank exercise book where the staff can note down brief details of what has happened to who, medication changes, what the doctor said, any falls, anything at all that happens really and that the next shift needs to know. If the staff can make brief notes at the time they think of them or when things happen it might jog their memory for when they come to documenting in the chart and they can use the diary to give report. You just have to be careful that staff don't write stuff in the diary but forget to put it in the chart. Or maybe set up a form with the resident names down the side and various headings across the top and they can fill in the boxes with brief info if anything has happened. It's double documenting I know, but otherwise the one LPN needs to read 20 charts at the beginning of each shift just to find out what's going on. Is this the sort of thing you're meaning or am I way off track?

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Specializes in LTC, MDS, Education.

Kardexes were Great! Whoever decided to get rid of them were orificees. I know I'm an old nurse but they were so helpful and written in pencil to facilitate updates. Back in the good old days, the Kardex WAS the care plan,,,,:smokin:

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I am an LPN that worked in a CAH that housed many swing patients at a time... so much so that when the census was full in the middle of the night, we would have to call the chief of staff to get the ones (that didn't need to be there) out, so that the ones that actually needed acute care could be admitted, or at least have a bed with a call light! I will say that this was a small, rural 25 bed CAH, and many of the "patients" were admitted more for the fact that the doc felt sorry for them than anything else. However, no matter if the patient needed acute or swing care, we were always on top of things as far as care planning. We didn't do the actual care planning, but end-of-shift reports were very complete... as far as "Patient B has a reddened coccyx, we need to take appropriate measures". A lot of it probably had to do with the competitiveness among the nursing staff and no one wanting to be "blamed" for the worsening of said condition. However, the reason our census was wall-to-wall all of the time was because people (in this small town, where people talk) knew that we could be trusted to not worsen their condition... and do everything we could do better it or at least make comfort our supreme priority.

I think, from what I've read, there needs to be some serious communication workshops going on. I know we were required (when I initially started as a CNA) to attend one I dreaded the day. But, really you are there for one reason and that is the patient. If you have nurses that aren't there for the patients and only for the "money" then weed them out. They don't belong in nursing and should be stripped of their license. Just my thoughts. Good Luck in your journey!

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The LVN does not initiate, evaluate or change the patient’s treatment/nursing care plan. The LVN participates in planning, executes interventions in accordance with the treatment/nursing care plan, and contributes to evaluation of individualized interventions related to the treatment/nursing care plan (Title 16, Section 2518.5).

That might be part of the problem... Technically RNs are supposed to do care planning. at least according to their scope of practice. I have no idea if they are ever trained or educated in school about care plans with that in mind...

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LPN's are taught careplans in school I am currently in lpn school and do them all the time

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Thanks so much for all your feedback. The system that exists here is alittle flawed I think as the RN on duty keeps to her ER/Acute care patients and has little to do with the LTC patients and the LTC nurse and CNAs take care of her patients and has little to do with the ER/Acute care patients. Report is even done separately (RN to RN, LPN to LPN and the CNAs aren't included in any report with the nurses). Talk about a breakdown in the concept of teamwork. I think that needs to change and the RNs need to be overseeing the care provided by the LTC nurses, which includes being involved with care plan development and maintenance along with the LPNs. I 've got my work cut out for me to change the culture here.

Thank you everyone.

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I wanted to add: to whoever said they love Kardexes I say AMEN. I'm an old nurse too and Kardexes were what we used to give report with and I guarantee nothing important got left out of the report since the items we needed to cover were all right there to serve as a cue. The person who suggested having a notebook in which important changes are written (new meds, condition of a wound, etc) and passed on from shift to shift was something similar like I was thinking of but I was thinking of devising a kardex in which there is a section for the offgoing nurse to write those things plus the patient's problem list and interventions (from the care plans) is also listed and incorporated in report. There is a nursing home about an hour from here that has 5 star quality rating and I was thinking of calling them to see if I can visit to see how they do things and maybe bring some of it back to our place --I'd like to not reinvent the wheel if I don't have to.

Regarding LPNs doing care plans: The state surveyors who come here have never said LPNs can't do care plans but I do think the RNs here need to become involved with the care of these patients too. To get our care plans updated I was thinking of pairing up an LPN with one of our RNs (there are only about 4 of each) to be assigned to getting their assigned care plans up to date, then the LPNs would be responsible to keep them up to date.

I'm a sincere believer that people most generally want to do things right (I know there are exceptions) and if they aren't doing it right you have to make sure they have all the information (education) they need to do it right. I think information/education and a good communication system is what is lacking for my nurses.

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