LTC - when residents deteriorate

[Meraki]

I am interested in the process for assisting residents in your facility when they deteriorate and require additional care. I am dealing with this with a family member and in the process of trying to get my grandmother proper care I am stepping on toes. It is an exasperating process.

The issue I am facing is trying to figure out who and how one determines and then communicates to all CNA's that someone needs additional help. Until very recently my grandmother did most of her care independently. I'm not even sure what has caused the deterioration as no one has spoken to us about her condition...in fact I was concerned they didn't notice. When I raised the issue with them initially they assured me they could offer her more help but that didn't happen. There are two CNA's on her section and they are very busy at bedtime which is when she needs the most help. There is also different CNA's working throughout the week so it isn't just a matter of needing one or two people to be on board. Management at this particular LTC is useless. The nurses and CNA's are almost all really nice, helpful, kind people who certainly seem fond of my grandmother but still haven't stepped in to fill this new need. One of them told me that they pretty much need permission from management to make her care part of their daily routine as until now she is 'designated' as independent care and so there is no time allotted to her. They also don't really realize how much difficulty she is having as when an aide/nurse comes in my grandmother becomes very stoic and insists she is fine/doesn't need help. Then when they leave she tells me she doesn't want them to know she can't walk/toilet herself anymore. She wants to be independent (but physically can't do the tasks now) and has the mindset that she is an inconvenience/burden.

I have been providing most of her care since she went downhill however I have to go back to work and I really the whole reason she is in LTC is to get help - but we can't seem to access that. I have a meeting next week with the DON to try and get somewhere and I gave a list of tasks she needs help with to the staff but the once night I didn't go in she didn't receive any help at all. It is so strange I really thought the staff there would step in and help her when she needed it and it is pretty upsetting to not see that happen. I'm not sure who though is dropping the ball. Do they need permission from the DON/manager? Is it the RN / LPN who assigns the CNA's their responsibilities for the shift? How is it communicated to casual/agency/part-time/floats that she now needs help? Is there a checklist typically or something they work from?

Any ideas based on your facility policies on how to get her on the 'list' to get assistance on a regular basis would be appreciated.

[Forever Sunshine, ASN, RN]

"Management at this particular LTC is useless. The nurses and CNA's are almost all really nice,"

Sounds like my facility to a tee. lol

So your grandmother doesn't get any kind of help at all from the CNA? Bedtime is very busy indeed but part of the CNA's assignment is to make sure all residents are clean, dry, and in bed. Even if she is designated as independent they still should be checking up on her to ensure this.

In this situation, follow the chain of command. Start with the charge nurse. If this hasn't been resolved, make the nursing supervisor aware. If it still hasn't been taken care of then go to the ADON/DON.

[SuesquatchRN, BSN, RN]

In this situation, follow the chain of command. Start with the charge nurse. If this hasn't been resolved, make the nursing supervisor aware. If it still hasn't been taken care of then go to the ADON/DON.

This. Unless you live in my area where everyone knows or is related to everyone else, in which case you just tell everyone in town including the administrator.

There should be a nurse manager on days, 7-3. FInd out who she is and make your case to her first.

[Caffeine_IV]

I agree with speaking to the nurse manager. I worked in LTC before and even the more independent residents received help when needed...I didn't know there was a certain process.

[Penguin67]

Find out if your grandmother's MD wrote the "independent care" order. That may be the origin. If it is, contact the MD, explain your grandmother's change in condition, and request that the order be updated to reflect the assistance that she now requires.

[mamamerlee, LPN]

I absolutely agree with calling the MD. Is the doc even aware of this change?

She shouldn't be asked if she needs help, that makes her feel bad. Instead, someone should go in and simply assist her - 'let me help you get ready for bed'. Is she toileting herself at all? I don't understand why bedtime would be different from other times during the day. I hope she isn't sitting in soiled clothes all day.

[coast2coast]

The nurses and CNA's are almost all really nice, helpful, kind people who certainly seem fond of my grandmother but still haven't stepped in to fill this new need. One of them told me that they pretty much need permission from management to make her care part of their daily routine as until now she is 'designated' as independent care and so there is no time allotted to her.

From experience with my own family members and working in LTC, this is the key to getting what you want. Your grandmother's caregivers are wonderful people who have WAY too much to do on a daily basis (probably). They need a higher-up to officially make time in their schedule for her extra care. They probably also need YOU to get this for them - which is what you are doing.

They also don't really realize how much difficulty she is having as when an aide/nurse comes in my grandmother becomes very stoic and insists she is fine/doesn't need help.

Simply discussing this with one or two CNA's is not enough - you need Doctor's orders detailing the changes in her condition and her new care requirements. Keep your meeting with the DON but really, really - doctor's orders. They will light a fire under ... the relevant parts .... of the LTC's management :)

[SitcomNurse, BSN, MSN, EdD, RN]

I really wish I knew what state you were in, because I would go to the NH and slap someone!

Primary issues in Nursing Homes, called Sentinel Events aqre the four late loss ADL's. Eating Mobility Transfer and Toileting.

If you facility fills out an MDS form, then they are reporting to the federal govt/medicare/medicaid services your grandmothers provided services.

It sounds more like an assisted living facility. Less of a nursing home!

If your Grandmother needs something, get in touch with anyone who will listen!

never be afraid to ask a question now that you might later say... I should have asked.....

[SuesquatchRN, BSN, RN]

Interesting. We don't need orders for anything to do with ADLs.

[ChaseThisLight]

I work as a CNA in KS, and anything having to do with ADL's and assitance with ANYTHING, we don't really need permission necessarily, unless it is out of scope of practice. In my experience, it just takes a family member talking to me to let me know what needs to be done. It is such a busy job, and if someone is listed as independent, unfortunately they will probably get overlooked to save time unless you specifically ask! A good relationship between family and a CNA goes a really long way! And whether you believe it or not, to most CNA's, these residents are as close to family as a stranger can be, so asking for help should be no problem. :)

Everyone is saying ask the nurse first, and that is the obvious answer IF the CNA won't respond to you, and if it is something that the nurse must approve. The CNA is the one providing most of the care, and it is sometimes a little insulting to have a family member go to the nurse before they talk to you.

[SuesquatchRN, BSN, RN]

Everyone is saying ask the nurse first, and that is the obvious answer IF the CNA won't respond to you, and if it is something that the nurse must approve. The CNA is the one providing most of the care, and it is sometimes a little insulting to have a family member go to the nurse before they talk to you.

We're always short and we have both excellent aides and aides in it for a check. The excellent aides would certainly do the extra care necessary but the lazy ones - no way. If it isn't in the instructions they simply would not. I need to know as the manager because by Medicare/Medicaid regulations the resident must be care-planned at the appropriate level to insure that we know what the resident needs and can appropriately staff and plan for that care.

We can't depend on always having caring aides (or nurses) on. It MUST be in the plan of care.

:)

[pedsrnjc]

Maybe a little off topic, but I really dislike the term "independant" in LTC; if the person were independant, they wouldn't be there. I have seen nursing assistants not go into a patient's room at all during their shift because the resident was "independant" (I helped thier resident). I think perhaps "minimal assistance" would work better because it implies that the resident still needs something. I know I can't change the world, but if I could, I would change that.

As far as your mother is concerned, I think meeting with the DON should help, but that's not until next week. Perhaps, you could call the nurse manager if you can't get in there between 7&3, the care plan should be changed. I don't think that a physician generally writes an order for "independant with cares", that's a nursing assessment. I hope things go well for you, keep us posted.