Need ADON for LTC Facility

BoopetteRN · Jun 16, 2007

I live in Illinois, and my facility has unit coordinators who run the unit, do MDSs, care plans and hold conferences. They problem solve and basically function as ADONs.

Daytonite, BSN, RN · Jun 16, 2007

your poor unsuspecting innocent. you are going to find ltc a bit different. nursing never changes. there are just piles of it to be done in ltc and things have to be organized. so, from that angle you'll probably find that a lot of things may need to be organized a little better. you'll also find that in ltc everybody like things to be in some kind of routine. it helps in getting all the work done. it's hard to change routines, so be gentle about that. let your creative juices flow. you can do that in ltc. another biggie is that some of the stuff that has to be done (documentation wise) is mandated by law. here's a link to the title 42 (medicare) law that applies to nursing homes: http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr483_05.html read through them at first so you have a overview of what is in them so you won't be standing around puzzled when the don and administrator start to talk about some of these things. your don can help you find your state laws on ltc.

to get to the actual clinical stuff. . .i found that calling the people who printed out the monthly medication and treatment sheets was a big help. they were very nice about working with me and telling me what their computer software was able to do. i discovered how i could change times on medications (their programs default to certain administration times, but this can be overridden). they were also able to send me a monthly list of all the patients who had dnr orders, tube feeding orders and things like that. one of my first big projects, and it took over a year to complete, was to start cleaning up and organizing the doctors orders on all the patient's charts. some of the charts had orders in them that were old and no longer necessary--they had to be d/c'd. it took time to do this because you have to follow procedure and get a doctor's order to do this much of the time. i also made sure that every chart addressed dnr status which was in the facility policy. each chart had to have "dnr" or "full code". i was involved every month with the monthly change over of the med and treatment reconciliation of these sheets which is how i organized that.

if your facility is required to do weekly nursing summaries, find out how they are organized to get those done. reorganize them if you have to. they are probably merged to the mds nurses reports. find out when v.s. and weights are supposed to be done and if they are getting done. reorganize how they are doing that if necessary. for the charge nurses, we pulled out the narrative nurses notes on the patients that needed to be charted on every shift and put them into a special three ring notebook so there was no doubt that the charge nurses knew who they were to be charting on. the trick is for them to also know what they were supposed to be addressing in their charting. if i were you i would put my head together with the mds nurse and find out how she lets the nurses know what specific information she needs for her mds reports, particularly the medicare patients. i found out at the last facility i worked that the mds nurse wasn't doing anything at all! so, i started paying her a visit after the admission of every medicare patient to get this information. the staff charge nurses have to be charting daily on the skilled aspect of each medicare patient's care. if they don't know what is making that patient "skilled" then ultimately the facility is going to be denied the medicare payment for that patient. medicare rules are very strict about what qualifies a patient for medicare coverage. if medicare finds that the care wasn't given (determined by the documentation), then the facility doesn't get paid and the administration starts looking for people to blame.

some of the other things i did to help the charge nurse staff to organize and keep compliant with state and federal laws was develop pre-printed fax forms (every thing is faxed to mds in ltc) to report lab results, patient falls, patient skin tears, fevers and requests for medication changes. these were not hard to do on a computer for me, but i was accustomed to working with msn word. we also had skeleton one page care plans for skin tears, falls, fevers, and diarrhea. the charge nurse merely needed to pull one of these out of the drawer and put the patient's name on it and fill in the date and perhaps the name of a medication or treatment that had been ordered by the doctor. i also designed new change of shift report sheets for the staff and lists that helped organize the cnas work (v.s.s, showers, weights, bms). if some of these are actual facility forms that end up in the patient's medical records you may need to get permission to change them. there may be a medical records person you'll have to work with on this.

we also had cna patient assignments already worked out ahead of time for 3, 4, 5, or 6 cnas per hall so there wasn't going to be time wasted at the beginning of any shift divvying out patients among the cnas. we had them pre-typed and slipped into heavy plastic sheet protectors. we could write on the plastic sheet protectors with black crayon and then copy the whole thing on a copy machine so each cna got their own sheet. these assignment sheets also had break and lunch times on them as well as little extra duties (clean the break room, certain utility rooms, etc.) for each cna to perform. it's nice to have this stuff, but make sure you check up on the cnas to see that they are actually following these instructions! nursing care in ltc a lot of times is functional nursing where you give one person one chore: do all the vital signs, or do all these weights today. that is very different from what is often done in the acute hospital.

the real biggie is going to be leading, guiding and, dare i say it, disciplining the staff (ok, i said it). by far, the biggest problem i had as a supervisor in ltc was dealing with the cnas and their behavioral problems. i'm not being in the least bit mean or nasty, but some of them are like children in the way they act and you have to know how to deal with the behavior. i can thank ltc and the many cnas with attitude for my knowledge on this subject. (#1) i recommend that you read well the employee handbook that has the rules that everyone is to follow. an occasional disgruntled or belligerent cna is going to quote them to you with authority and you need to know if a particularly intimidating individual is quoting them to you incorrectly as they will tend to do to get their point across and win an argument (i'm not kidding here). if you don't play a part in enforcing the facility rules, then there is going to be anarchy. just read some of the posts on allnurses about some of the renegade cnas that some of the charge nurses have to deal with. it happens when rules don't get enforced. (#2) read the section in the policy and procedure manual on disciplinary action, make a copy of it and know it. discuss with the don how she wants you to handle discipline with employees because i guarantee that it is going to come up and you are probably going to be the one it comes to first or the don is going to delegate it to. people with no backbone don't belong in leadership positions. this is just one of the unfortunate duties that comes with the job that you have to learn to do. it's that, or anarchy. (#3) documentation. if you don't know how to write a memo, it's easy enough to learn. in ltc, employees get written up by documenting what they did on any old piece of paper and it is given to the don. i was always professional about it and put these write-ups in memo form, typed. they were just factual accounts of incidents of employee misbehavior, but the don needs them to do any serious disciplining or firing of a person. you are going to learn, if you've never been in management before, that indiscretions have to be documented. (#4) if you've never had to stand up to a belligerent or insubordinate worker then you need to review some assertiveness techniques. this is a skill that is only honed through practice and you're likely to get plenty of it in ltc. i did. remember this. keep your temper. in many cases you're dealing with people who are acting like children. you've got the education behind you, so use it to your advantage to find the principals of assertiveness and affecting change. don't participate in gossip as other employees are always curious about what's going on. and, remember that everyone is entitled to confidentiality. here's two websites where you can bone up on assertiveness:

http://changingminds.org/techniques/assertiveness/assertiveness.htm - assertiveness
http://www.dlsweb.rmit.edu.au/toolbox/fmi/content/tutorial/assert/assert00.htm - assertiveness tutorial from australia. includes sound clips of examples.

i also have a couple of books that were a great help to me:

managing difficult people: a survival guide for handling any employee by marilyn pincus
working with difficult people by muriel solomon

i'm sorry if you think i'm focusing too much on this people factor, but this was a problem at some point or another in every single ltc i've worked in, and i've worked in a number of them over the years. as an adon these problems are going to get dropped in your lap.

the other big chore that came to me was staffing issues. next to dealing with difficult people, this one took me the longest to learn, but i learned it first in the acute hospital as a nursing supervisor. if people called off i had to get on the phone and find staff. if it involved cnas i was calling the cnas who were off that day or the staffing agencies. if it involved licensed nurses, more of the same and sometimes i was having to take an assignment myself. you will find in ltc that the nursing management staff sometimes has to fill in as charge nurses when there are just no licensed nurses to work an open spot. as a management person you may be subject to having to do this for any shift on any day of the week. in one place, we had half the staff call off one christmas day.

i don't know if you can find anything useful on this site, but this is the home page of the national association directors of nursing administration in long term care. http://www.nadona.org/ . they may have articles or publish materials that may be helpful.

Nascar nurse, ASN, RN · Jun 17, 2007

Daytonight stated that everything gets faxed to Dr's, ie: labs reports, etc. Before you do this check your policy. We were cited by state for doing this as we had no actual proof that the physician was ever really notified - we couldn't prove it got sent to the correct number, that the fax was working the day we sent it &/or the physician actually read the reports (as opposed to get buried in a pile of other papers). We are required to call all reports is - no faxing. I'm sure this varies state to state - check policy first.