Latest Comments by pixie120

pixie120 4,478 Views

Joined: Jul 30, '11; Posts: 255 (30% Liked) ; Likes: 174

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    Quote from PsychNurseWannaBe
    Our charting is pretty straight forward thanks to our software. We select MC: and the admitting diagnosis... it then takes us through whatever assessment it is looking for. For example MC: Rehab for functional loss, or MC: Pneumonia, MC: Hip fracture, etc. Our nurses do the assessments but it is up to us to interpret the information and incorporate it into the MDS and CP process.

    We have report every morning. We make copies of our 24 hour report and head off to the meeting. We do not have "MDS" nurses. We are nurse managers in charge of everything that gets thrown our way. I would not want floor nurses to do the MDS process. It is not as easy as pointing and clicking. The question on the MDS might sound simple until you check the RAI and get a 2 page explanation on what NOT to include in the one loaded sentence they asked. Furthermore, I do not want them to do care plan because in the end, I will be the one answering to the state. My nurses do not have time for such things. I need them to perform assessment on critical patients, run the unit, supervise the CNAs, ensure showers and cares are getting done, medications passed, orderd transcribed, MDs called, labs reviewed, family dynamics, admission and discharges, etc. They have enough on their plate. I'm sorry but if your MDS nurse is having such a problem, then I suggest she spend some time with the nurses and explain what she needs from them. I apologize again, because it sounds like she is pawning off her work onto others.
    I understand the floor nurses are busy, when they get a new dx/treatment, all they have to do is turn to the careplan, handwrite somewhere a new C/P: UTI goal: Resolve UTI Interventions: ABO as ordered, montior for ASE of ABO, report s/sx new UTI once ABO done. Takes a minute. Good practice, good for all. Surveyors just exited our building, spent far more time with floor nurses than ANY of the nurse manager staff. IF your floor nurses were to say "Oh, I dont' do that, the MDS , RCM, SDC, DON does that.........." Really, and are they the primary care nurse? It doesn't fly. The more times they practice a short term c/p the faster they will get at it. Same with elopement, new fall, new injury, interventions are just whatever you are doing right then for the patient.

    THe nurse managment team can come behind later and tweak the careplan. I have been for over 10 years as a nurse manager, careplanning events I never witnessed, wasn't in the building when it happened, and now have to investigate, re-interview etc and then careplan the event. It can be careplanned, investigated immediately, takes a few moments, the more you do, the more you know and the more it makes sense to you. (That's how I learned....).The witness statements need to be filled out right away, by the C.N.A, then the nurse careplans it, so...if the nurse adds a wanderguard, go careplan it short and sweet. The number of resident's that the nurses are now expected to care for has dramatically dropped, taking care of 15-18 residents, in LTC is very doable. Medicare 10-15 very doable. No time to sit around and cry,whine and point fingers...and if you do, PLEASE careplan that!! And in this state, the economy is affecting nurses as well, and we are finally seeing nurses understand that and be willing to step up to the plate and be part of the nursing team. Communication is everything. If the floor nurses can't do short term careplans, or if they say they don't know how or don't have time, get them some training and support them in this learning process. If they have their heads buried in that bloody MAR, for god's sake stage an intervention. MOst of those meds are completely benign, useless and if the floor nurses would speak to the families and MD, can whittle those meds off that bloody MAR, and then focus on the actual patient. Careplanning and updating the CNA careplan/Kardex if far more important than making sure 89 year old Wilma gets all 16 of her bloody vitamins, plus one important med.

    WHen I was running a 40 bed dementia unit, we whittled those drugs down to the barest nubs of important cardiac, HTN meds (and some of those can go away as well, ask the pharmacist if you aren't convinced) and no less than 10 had NO meds, ZERO, (and they had a ton less behaviors as well) we made a boatload of Hospice referrals and we focused on pain meds and bowel meds, and then...activities. We took a 4 hour 8 am med pass and got it to less than 1-2 hours, so the floor nurse could supervise the cares given. We also did a ton of care conferences and met with families to increase/personalize the care given, care goals. Yes, it takes time, but it is so worth it!!

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    Quote from PsychNurseWannaBe
    IDT signs the same sections on the MDS depending on what it is. You will see this with electronic signatures. For example, I open the MDS and put in the ARD, section A. SW comes around and answers the questions about mental disabilities. I put in information regarding O for treatment and procedures, but therapy puts in their own minutes. I don't touch mood, behavior, swallow, cognitive, activities. There is a reason why it is called an Interdisciplinary Team. They can code their own speciality. I just oversee that they do things correctly and timely. They are also responsible for their respective CAAs and CP... again, I ensure that they are timely, correct with appropriate interventions
    Thanks for the information. We review all MDS data, as an IDT, every morning and do the quaterly/comprehensive assessments (Braden, AIM etc) and write an IDT note per each MDS due. We double checked, we are able to combine MDS nurse note with IDT note (it's in Section 2 of new updated MDS manual). It would be nice if the other disciplines did their own data entering but I have to say I much prefer this way as even now, the two other non-nurse staff have to be reminded/prodded to get their sections done and it really holds up the MDS train. I worked in several buildings such as yours, where there were just as many non-nurses "responsible" for entering their MDS information (including the Restorative nurse/RCM's for the RNA portion, Kitchen manager for the weight section) and MDS's nurses were ALWAYS in a dither to get those folks to do their portion. Given that NOW we are in the new, "real time" MDS and "real time" opening the ARD date, and given particularly for the COT's etc, I am very glad it is mostly RN's. I like our new system as well, very IDT.

    Also, just as an FYI, it's not the MDS that has to be IDT, it's the assessment, careplanning and review of patient care that has to be IDT, which of course included the MDS, we just reviewed the wording, it's all nursing process, the 5, with the IDT meeting weekly or even daily to assess, plan, implement, review and re-assess). MDS is one part of that IDT process. Many things that SNF's have implemented in the last few years with regard to focus on IDT compliment the new MDS as well. Just my two cents...

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    FYI, in this building we have 3 RN MDS/RCM's, is probably why they do the "extra" work that some don't? Max patients per MDS/RCM is 20, Medicare mixed thru out all caseloads

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    Thanks for the information. Perhaps I asked the question wrong. In our building the SW does D,E, Q Activities does F and RN/MDS does the (including CAA's) so my question is this: RN signs for and puts these alphabet letters:
    A,b,c,g,h,i,j,k,l,m,o,p,V and Z Correct? (RN's imput all data from Dietician, Therapies, only other disciplines who data enter, in this company, are the SW and Activities, RN's do the cognition section).

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    Quote from andy3k
    RAIM3 (RAI Manual MDS 3.0) pg 2-41 says, "The requirement to complete a change of therapy is reevaluated with additional 7-day COT observation periods ending on the 14th, 21st, and 28th days after the most recent Medicare payment assessment ARD and a COT OMRA is to be completed if the RUG-IV category changes."

    In other words, the COT is repeatedly reevaluated every 7 days starting from the most recent PPS assessment ARD.
    Ok,good to know. Next question, the PPS folks that were "grandfathered in", they do NOT have to be looked at continously every seven days? (The folks that admitted and had their 5 day, 14 day Assessments,or even their 30 day or 60 day.. rehab is saying, based on their company training, we do NOT have to evaluate them, just those that admit after 10/1/2011).

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    Quote from Ruas61
    Primary responsibility for accuracy lies with the person selecting the MDS item response. Each person completing a section of the MDS is required to sign the Attestation Statement (AA9, AD, and AT7) that reads:
    �I certify that the accompanying information accurately reflects resident assessment or tracking information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from Federal funds. I further understand that payment of such Federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.�

    This is what I base my practice on. It would be interesting to see how people interpet it.
    Umm...exactly. and when other's won't participate, give that information, it becomes quite a quandry doesn't it? Another great thing we just had implemented, MDS nurses now have direct access to the therapy documentations and minutes, how wonderful!!!! We are though, struggling with this COT issue... oh, well, we will figure it out soon!

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    Quote from katoline
    Pixie, you are smart and you are passionate. tread lightly, do the MDS nurses report directly to you? or do they have a corporate, regional/district sometimes consultant like person? I've seen you from other posts under MDS and am an MDS nurse myself, have been an ADON, offered DON (wouldn't think about it ;-)
    and no, i don't feel that submitting an assessment without all the information is fraudulent, submitting incorrect information knowingly is fraudulent. If an assessment will be late if you don't submit and you can't get the information you need from therapy, it doesn't change the assessment, only the reimbursment. If there is a regional/district whatever MDS person, he/she should get involved. Issues such as these are going to make a BIG BIG difference and you're right, it didn't take long, did it? you are new, intelligent and have knowledge that apparently others there don't have. you are seen as a threat. you might know too much to be able to tone it down. in that case, a better organized, more knowledgable company may be your best bet. Good Luck! you'll find your nitch.
    Appreciate your post, somehow I didn't see it until today.You are so very right, I can't hide what I know....sad isn't it? I am interviewing for several jobs in the area in companies that seem to have a much better handle on this. I will make sure going forward, the support system is in place to make the job easier. THAT has been my lesson this year, lol!

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    Quote from CapeCodMermaid
    Post acute unit: 27 patients day shift 2 licensed, 4 cna's, 1 nurse manager, evenings 2 licensed 4 cnas, nights 2 licensed 2 cnas
    2 long term units 39 beds: days 2 nurses + manager, 6 cnas, evenings 2 licensed, 6 cnas, nights 1 licensed 4.5-5 CNAs
    dementia unit: same as above, but nights has 3 cnas
    This is the best staffed facility I have ever worked in.
    My last building on sub acute for 41 residents we had 4,3,2 cnas, long term / dementia for 41: aides were 5 5 and 2, and the other unit 4,3, and 2 with 41 residents half of whom were independent with adls.
    Would you mind if I asked what your PPD is? Must be about 3 or a little under/over? (For Skilled).

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    Nascar nurse likes this.

    Quote from Nascar nurse
    Thanks to both of you. This QIS survey process is somewhat frustrating. I'm used to trying to manage a survey process. I'm used to knowing what they were digging into, I'm used to trying to "argue" why we did what we did, etc.

    Heck I might as well go on vacation with this process. I don't have a clue how we are doing. Could be good/could be bad. Think that makes me more nervous than anything.
    Yes, in a wierd way, it does seem much more detached, and as they don't do a verbal exit everyday, sometimes you can actually take a breath here and there. Days 1-3 are not too bad, it's when they go into stage 2 that gets a little rocky. If you want to know WHO will be looked at, pull your QA/QI report, and pick your top 10 (and include skin in that top ten, plus any Hospice, endof life folks). THEN, pull out your blank incident reports, your state hotline number and get ready for the "allegations"that never fail to come out during QIS. This is my 2nd QIS survey, and my 3rd survey in less than 10 months, maybe I'll be a pro at the end of this one? My only complaint is when they are parked in the nursing station, phone/fax ringing, trying to do patient care etc and all 4 want something, HaHa! It does make the days fly!! Best of luck to you! We are in day 3 today. ( I might regret saying this, but I am starting to like QIS a lot more than the old way, those bluepapers, jammed pack full of the hand written documentation,and then daily exit were a bit much, so....subjective).

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    Quote from Ruas61
    Yes every 7 days starting with the first ARD in October.
    SO it would go like this: day one, then 5 day, 14 day, 21 day possible COT, day 28 (30 day would fit here), day 35 possible COT, day 42 possible COT.....thru day 100.
    I though I read that a COT has to be reviewed for and done 7 days AFTER that last ARD date of an MDS,...if thereis no COT at 35, then why would we look at a COT for day 42? (I do understand the idea that we are to look at their "rug" level every 7 days...but it is associated with an assessment date/period/ARD? So.. if no COT (cuz therapy still RU on day 35, we still look on day 42?). Kinda makes the grace days obsolete then?

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    Best words of advice I ever got were 1. Never let them see you sweat 2. Tell the truth 3 Continue the best practice care that you always give, as if it were just another day!

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    Quote from katoline
    I don't know if this will help, but here goes. i worked at a 120 bed facility and did mcr assessments. when we got to 35, it was getting hard for me and i had to ask my coworker to help. but then i have never worked in a facility, maybe one, where the other team members did their part of the assessments, at least timely. nor did they do RAPS/CAAS. They did do thier own careplans. That said, i guess it would depend if you just do certain sections.
    an unlicensed person could do data entry and scheduling as you said. how about section A if taught? maybe even enter ADLs, mood or behavior if you just go from print outs off a kiosk. doing the entries/reentries would be a help as well as opening the assessments. printing out, organizing with notes for review, signatures, and to do filing. we have unlicensed people put MD orders in the computer, diagnoses, once taught or given by others and those populate the MDS. But with all the new discharge assessments and now COTs, i believe you need another licensed person, at least part-time if you have the unlicensed person as well, could be an lpn/lvn. all you would have to do is sign as complete, not that it is correct.

    And oh yes, very overwhelmed, especially because i think other disciplines don't have a clue sometimes what all we do and how much.
    Kudos for saying that last line, the other disciplines are kinda irritated with nursing, in our building, sort of an us vs them, "just because nursing has to do another assessment....". I think they just don't get that they are also going to have to do assessments in their sections, we don't know yet all that is going to occur, and I get the feeling that some are trying to hide heads in sand, cuz it's gonna be a bumpy ride. We have dedicated MDS nurses 2 for about 75, Medicare about 15-20 average and a couple of HMO's. MDS nurses do the careplans, other's do the quarterly assessments. They are already irritated that we moved up many MDS's to get done by 9/30/11, so we could concentrate for the change. Thank-fully the rehab manager has had extensive training, albiet kinda late in the game, but training none the less, I think therapy is going to be the busiest, and their goals are now changed to attempt to keep rates at the same for the 5d 14 d and 30 day which typically is the same, at least for the "real" rehab clients.

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    Ok, here is my question. please check my math here"
    In looking at all of this, for PPS/Med A, potentially there are ONLY 4 COT's that could possibly trigger? In a perfect world:

    5 day: if a COT triggered, would be a combo for 14 day, right? (No matter what day chosen, if even day 8, cot would be due day 15, but the 14 day would also come into paly
    14 day: could have one COT on or about day 21
    30 day: if a COT triggered, on or about day 37
    60 day: if a COT triggered, on or aboutday 67
    90 day: if a COT triggered, on or about day 97, but there would also be an opportunity for a quarterly in here, as well.
    ....and then,.... if 6 people get off at the last station,....what is the name of the conductor> lol!! (My administrator says that what a PPS meeting sounds like to her, if this was 6 then this would be 8 and then if this is 9, that is an RUX, lol!!).
    And of course, we will review daily for any possible COT's, correct?

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    Quote from crissrn27
    I went out in June of last year just as we were gearing up for 3.0. I was on bedrest for 26 weeks with my son and after he was born discovered they had replaced me so I have been home with him for the last 9 months. So a total of 16 months out of the loop.

    I had an interview today for MDS at a similar nursing home (60 beds, similar mix) and the admin who interviewed me made me feel like my experiance was of no use since 3.0 was started. I have been doing my homework to prepare for the interview and while there were many changes it seems that the process is still very similar to what I have been doing for many years.

    Is the admin correct? Am I now in the same place as any nurse walking in with no training/experiance in MDS? I'm not sure where to go from here. There are no on site trainings avalible in my area and I'm not sure about a online training. Any advice?
    Lots of updates on the CMS sites, and this is a great resource. Good luck (I think your MDS 2.0 experience serves you well, but you gotta frame it up better that you have been studying, on your own, well aware of the LATEST changes 10/1/2011 with the COT's etc, and sell it to them. I think everyone is a little freaked out this particular MDS week, lol!

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    WHen I worked Assisted Living, the pharmacy did our MAR's, and they were always written as per community prescription, ie Tylenol 2 325 mg tabs twice daily as needed. LTC: pharmacy will begin doing our MAR's when we switch over to E-Mar this month, HOWEVER the kicker is, only for the meds they we still have to input the OTC's. We anticipate lots of tinkering is going to be needed. Are the pharmacies giving any guidance on this issue? FOr years, it has been written as the total dose to give, then it's up to the nurse to supply that dose, in as many tabs is needed, however I haven't liked that system since I saw how more accurate the Assisted Living MAR's are. I would think that best practice is WHAT you are actually going to give, BUT a surveyor during med pass audit will say if you give that long acting Tylenol 650 mg it is NOT the same as Tylenol 2 tabs of 325.... Suggestions?