Not following care plan

pagandeva2000, LPN · Aug 3, 2007

Just out of curiosity, how many of you LTCFs out there stick faithfully to a resident's care plan? I posted this on the regular Geriatric/LTC nursing board, too for a nurse's perspective, but since CNAs do pretty much all the transferring work, it pretty much belongs over here!
When doing transfers, do you use gait belts without question? Is there always two to a Hoyer transfer? Are two-assists ALWAYS two, or does the one big guy handle them all by himself? I am one of those aides, I do everything to the care plan faithfully because I am not the strongest person, for the safety of the resident, and I don't want to lose my job. But so many of my coworkers are NOT the same way -- in fact, come to think of it, I don't know if anyone is like me that I know of.
One of our strongest workers, an older male, recently lifted a two-assist by himself and fractured her hip in the process. She will now be a Hoyer and has been in and out of the hospital for decline. He has been fired since for transferring another two-assist resident by himself. So our LTCF has really been cracking down on it, I'm surprised more people aren't religiously sticking to that gait belt, and other transfer rules!
What is the situation like at your facilities?

I am interested to know the answers to this myself because when I went to CNA school, or even when I worked for a nursing home, I was NEVER trained in following care plans (this was over 12 years ago). I got written up once because I placed up two side rails when there was supposed to be only one and the patient fell out of the bed. Never once saw the care plan, never knew it existed. Now, I would advise CNAs to ask to see the care plans for their clients. As a nurse, now, if I worked in a nursing home, I would leave clear instuctions on the care plan what needed to be done.

AmberL, BSN · Aug 3, 2007

My coworkers and I always have 2 people in the room for a hoyer. I try to use gait belts all the time but sometimes I transfer people without. And some residents that are two people I can do by myself but for the most part I use 2 people.

casi, ASN, RN · Aug 3, 2007

I work in assisted living, so transfering methods are a little different.

I always use a gait belt when it's required. It's easy enough and right there to use. When it comes to assist of twos it all depends on who and what is available. If there is an assist of two and I'm on an unit where there's only me working if the person is light enough I'm doing the assist by myself rather than call someone to come up to the unit. All assist of twos are supposed to be a mechanical lift, but half the rooms you can't fit them into and the hoyer and ez stand are left on one unit and when someone has to go to the bathroom you're not going to say "Give me five minutes I have to go down stairs to get the ez stand."

The whole care plan thing in my facility rarely works. Care plans are updated once a year, they are rarely changed at the once a year update, and are never changed as a resident declines. So if you use the care plan you maybe giving innappropriate care.

indierock · Aug 3, 2007

most of the care plans for my residents are out dated.

For hoyers and sit-to-stands, i always use two people. No questions asked. As for the two person, nonmachine lifts, it depends. Im not a big burly guy (actually i am a little woman, 4'11", 120 pounds) but a lot of these people just need the right approach to get them to do enough work that it would be a one person assist. It all depends on the resident i guess. Once you work with a resident for long enough you begin to realize their strengths, weaknesses, and what they bluff about not being able to do. For new residents or if i haven't worked with someone in awhile, i go to the cnas that do. They know more about how someone transfers than the care plan could ever tell you.

pagandeva2000, LPN · Aug 4, 2007

So, is there more emphasis on the care plan in CNA school, now? They didn't do this when I went years ago. And, are they orienting you guys to following the care plan at work? Thanks for sharing.

casi, ASN, RN · Aug 4, 2007

They really do emphasize that we need to check the care plan before doing anything with a resident/patient. Unfortunately in both CNA jobs that I have had they mention nothing about checking the care plan. I believe at both jobs discovering where the care plans were kept was a bit of a random discovery.

It would be really nice if long term care/assisted living facilities did have updated information available for CNAs.

amanda1229 · Aug 5, 2007

I work in assisted living, so transfering methods are a little different.
I always use a gait belt when it's required. It's easy enough and right there to use. When it comes to assist of twos it all depends on who and what is available. If there is an assist of two and I'm on an unit where there's only me working if the person is light enough I'm doing the assist by myself rather than call someone to come up to the unit. All assist of twos are supposed to be a mechanical lift, but half the rooms you can't fit them into and the hoyer and ez stand are left on one unit and when someone has to go to the bathroom you're not going to say "Give me five minutes I have to go down stairs to get the ez stand."
The whole care plan thing in my facility rarely works. Care plans are updated once a year, they are rarely changed at the once a year update, and are never changed as a resident declines. So if you use the care plan you maybe giving innappropriate care.

Wow, that's so weird! I can't believe you only have the CPs updated once a year. I would say each resident on my wing, except for the more independent ones, has a change on their CP at least every month or two. But then again, I work in a LTCF, not AL.

That's so typical about the EZ stand and Hoyer situation. Thankfully, we only have one level and don't have to worry about going up and down to get them, but there's only one to share among three wings that each have at least two Hoyers (and my wing used to have nine!). We always use them anyway, but I've seen some aides (since discovered and terminated, but still) just brush off the lifts and transfer them themselves if they can. I'd never have the guts but I don't judge them, and almost blame our the brainless logic behind one Hoyer!

amanda1229 · Aug 5, 2007

They really do emphasize that we need to check the care plan before doing anything with a resident/patient. Unfortunately in both CNA jobs that I have had they mention nothing about checking the care plan. I believe at both jobs discovering where the care plans were kept was a bit of a random discovery.
It would be really nice if long term care/assisted living facilities did have updated information available for CNAs.

It seems like so many of you can't even find the care plans! That's so weird, both places I've worked at (my job and where I did my training) had them right on the back of the door -- I look at them everyday to check for updates. For those of you with really active MDS coordinators, I would suggest THIS location.

It also seems like a lot of you are like the CNAs where I work, they'll usually do Hoyers with two people in the room, but they do almost all of the two-assists by themselves. I'm more of a square, I just can't do it -- aside from worrying about the resident, I also date the brother of the MDS coordinator at my LTCF so I'd be naturally careful anyway.

pagandeva2000, LPN · Aug 5, 2007

It seems like so many of you can't even find the care plans! That's so weird, both places I've worked at (my job and where I did my training) had them right on the back of the door -- I look at them everyday to check for updates. For those of you with really active MDS coordinators, I would suggest THIS location.
It also seems like a lot of you are like the CNAs where I work, they'll usually do Hoyers with two people in the room, but they do almost all of the two-assists by themselves. I'm more of a square, I just can't do it -- aside from worrying about the resident, I also date the brother of the MDS coordinator at my LTCF so I'd be naturally careful anyway.

I think that maybe placing it behind the door (are you meaning behind the client's door to his room?) may be a HIPPA violation, and that is why they may not be placed there in every place. Logically, though, it is the better location, where each aide can see it.

I am hearing that some have books with the care plans in them that relate to the duties of the CNA, according to assignments. There may be a book for assignment #1, which is from rooms 1-10 (an example). It is also interesting to hear that CNAs have been terminated for not following them. Were they counseled first, at least?

Oh, yeah, if I were dating the relative of the MDS coordinator or anyone at the facility I work for, I'd be careful, too.

pagandeva2000, LPN · Aug 5, 2007

We always use them anyway, but I've seen some aides (since discovered and terminated, but still) just brush off the lifts and transfer them themselves if they can. I'd never have the guts but I don't judge them, and almost blame our the brainless logic behind one Hoyer!

Were these aides counseled first before termination? And, were they reported to the state? This is shocking news to me; I say this because when I was a CNA years ago, we weren't shown care plans during orientation where I worked in a nursing home. Once, I placed a client in bed and put up both siderails (because I didn't see the care plan) and he fell out of bed. I was written up because I was told that maybe the client panicked by seeing both siderails up. My union was with me and told them that I wasn't oriented to the care plan (I think that nursing home called them assignment logs or something close to that) and it didn't go any further. The nurse was forced to show me the sheets where the assistive devices and side rail requirement was AFTER the fact.:angryfire

amanda1229 · Aug 5, 2007

I think that maybe placing it behind the door (are you meaning behind the client's door to his room?) may be a HIPPA violation, and that is why they may not be placed there in every place. Logically, though, it is the better location, where each aide can see it.
I am hearing that some have books with the care plans in them that relate to the duties of the CNA, according to assignments. There may be a book for assignment #1, which is from rooms 1-10 (an example). It is also interesting to hear that CNAs have been terminated for not following them. Were they counseled first, at least?
Oh, yeah, if I were dating the relative of the MDS coordinator or anyone at the facility I work for, I'd be careful, too.

I'm sure it's not a HIPPA violation here, we've always had them up. We also have Skin Alerts posted by each bed (unless the resident has absolutely no concerns), and any other alerts posted nearby. Our LTCF is in good standing, so I'm sure that these aren't violations where I'm from ...

We also have resident chart books with the careplans in them, but it's so much easier to have them right where we can see them, half a second away from the resident!

Were these aides counseled first before termination? And, were they reported to the state? This is shocking news to me; I say this because when I was a CNA years ago, we weren't shown care plans during orientation where I worked in a nursing home. Once, I placed a client in bed and put up both siderails (because I didn't see the care plan) and he fell out of bed. I was written up because I was told that maybe the client panicked by seeing both siderails up. My union was with me and told them that I wasn't oriented to the care plan (I think that nursing home called them assignment logs or something close to that) and it didn't go any further. The nurse was forced to show me the sheets where the assistive devices and side rail requirement was AFTER the fact.:angryfire

We have had countless inservices about safe transfers and following care plans. We also have a very assertive administration and MDS coordinator, with these inservices and instructions, along with the care plans posted in easy view and frequently updated. Any employee (nurse or aide) that has been terminated on account of not following the care plan at OUR facility has definitely been warned. We are told at official inservices that it's our final warning. And why shouldn't it be? We are oriented to the care plan, and are oriented to understand how important it is at our facility -- anyone who is just in too much of a hurry to follow them isn't someone they want around!

I know it's different at every facility, but I don't have any sympathy for people who can't follow the care plans when they're told how important they are AND told of the consequences -- not at our facility.