Our LTC facility going "skilled"..problems

txspadequeenRN, BSN, RN · Oct 14, 2005

My facility is 100 % medicare certified, meaning all beds are avaible for medicare patients. If it is charting your having trouble with let me see if I can help. This is some of the things I chart on.

First I list that they are on skilled services.

"Resident on skilled unit for pt,ot st and nursing managment"

Then I look at what things therapy does for them .

" seen for ADLS, gait, strength, and group therapy"

Then I go into

alertness and orientation

redirection if needed

any behaviors that limit therapy or function

Incon or cont

feeds self or staff assist

transfering and ambulation max assist x1 or mod assist . Make sure you chart the max help needed, more money for the facility

chart your assessment , I do breathing , pulses, bowels sounds, pain if any , wounds being treated, edema and any other assessment findings.

Medicare requires that the patient be taught something at least once a day so chart on something you taught them. I always do " resident educated on AM meds purpose and desired effects".

Dont forget V/S

I think thats about it . Maybe I have left out some goodies , hope not.

Good luck to you and I hope this helps...

Okay, trying to keep our heads above water at work. The LTC facility I work at applied for, and recived a "skiiled" status, with Medicare number to boot. Now, our DON, administrator told us that we would have all the training we need, and knowledge, BEFORE they took any "skilled" residents, LIE nuber one, they have taken now a total of 3 "skilled" residents, and we have had nothing but a 1/2 hor meeting on charting for these residents. Now don't get me wrong, I don't mind about the skilled aspect, the things I mind is the more work we have to do, with no more staff,and no training so to speak. We are trying to band together as nurses at work, and we want a raise, as we are pretty low paid, but not of course to management, even though we did our own survey in town and know we are, we want the use of med aides, now they let us use the one or two we have, but they are working on the floor as CNA's also, so it is harder for them, and with out additional pay...so...has anyone else gone through this transformation, and how did it go, any advice??? 99% of us nurses have not worked anywhere else, and therefore it is more difficult for us to make this transition. They told us at first we would not have more than ONE skilled per wing...lie #2...HELP....
thanks! any advice is appreciated.
JoBug

CoffeeRTC, BSN, RN · Oct 14, 2005

I've never worked in a facility that wasn't medicare certified, so I'm a little lost on the change over aspect.

What type of charting were you doing before. Medicare skilled requires daily charting and assessments q shift. Some facilities chart q shift on all medicare residents. We only chart q day and spilt it between days and eves. What is staffing like now? What type of pts do you have now?

A great site is AANAC.org. great info for careplanning and MDS and PPS questions.

JoBug · Oct 15, 2005

Thank you for the charting info, it will be VERY usefull to me, as I will be working on that wing this weekend. VERY much appreciated!

for our facility, we are a 80 bed nursing home, with two wings, one wind has 50 residents, with 4 CNA's and one nurse, the other wing has 30 residents with three CNA's and one nurse. This is for second shift, on days they have one more CNA on each wing, a bath aide, and a "float" nurse, who does the treatments and takes the orders. Our charting prior to this was a chart by exception type charting, no real charting type so to speak. I suppose we have had things very good prior to this, and proboly spoiled by not being medicare certified, but, now we are and are trying to muddle through it, I just wish we had more knowledge prior to it, because I wouldn't want the facility not to get reimbursed, and it be my fault, and I know all us nurses feel like this. So I suppose the years of not being medicaide certified, and not having all of this mandatory charting that we are not used to will be an adjustment to us all. They have decided that they are going to put the "certified" residents on the 50 bed wing, because it is the "newer" wing that is all handicaped accessable, being in rural Iowa, things are different proboly than the newer up to date facilities across the country. They do want us doing shiftly charting in great detail, and I guess it will be hard to get used to, but no the less we will

thank you for the site, I will check it out.

JoBug

OneChattyNurse · Oct 15, 2005

when my facility went through "the change" we had a binder that had a "cheat sheet" for the more popular shilled diagnoses such as cva, hip fx, pneumonia, etc.... we would copy the sheet and temporarily put it in the chart as a reference each time we went to chart on that patient. this way were to sure to get all of the required charting completed. where i work now, we have a check-off sheet that goes through each system and has room for narrative charting as well. it is a great tool as there is room for 24 hours worth of charting on one sheet. if you developed something like this and presented it to your don maybe he/she agree to using it for all of your snf patients.

good luck to you!

BowlerRN · Oct 15, 2005

I've always worked in a Medicare skilled facility, we have a flow sheet for all Medicare patients, which is basically a head-to-toe assessment:

LOC/Orientation

Skin Color/Temp

Skin Turgor

IV Site

Heart Rate/Rhythm

Respirations

Lung Sounds

Cough/Sputum

Pulses (palpable, weak/strong/thready etc.)

Abdomen (soft/nondistended etc.)

Bowel Sounds

Urine Color

Voiding Difficulty

Edema

Homan's Sign

Pain/Med given/Relief

This little checklist doesn't take long to do once ya get used to it, hope I didn't forget anything. We are also required to chart every shift. The aids get VS every shift. In my actual Nurses notes I usually include any of the above that are out of the ordinary any work I've seen the res. doing with PT or anything they've reported to me, if on O2 and sats. I also include amount of assist needed with ADL's. It's really not that bad once ya get used to it. I work in a 44 bed LTC facility, on the 2-10 shift there's one Nurse, 2 CNA's and from 4-7 an unlicensed employee who keeps track of the Alzheimer's res. (This is extremely helpful and has decreased our # of falls.) We currently have 2 skilled resident.

bellcollector · Oct 15, 2005

I agree that the charting is pretty simple once you get the hang of it. I would be more concerned with the staffing depending on the acuity of the new skilled pts. If they are needy pts then staffing is always a problem. I wish you luck and be sure to protect your back. The back is usually the first thing to go in LTC nurses.

Daytonite, BSN, RN · Oct 15, 2005

Hi, JoBug! One or two of the hardest jobs I've had was working on "skilled" Medicare halls in LTC facilities. These patients are of a much higher acuity than the regular run of the mill nursing home patients. You will be pretty much doing the work of an RN on a medical unit in the hospital. Having sat through a couple of meetings with consultants one LTC brought in for inservicing us told us that they usually recommend that facilities put all their Medicare patients on one wing, hall or one particular area of the facility. The reason is because the nurses who work with these patients have to be aware of what makes these patients "skilled" and to be able to document properly on them. What makes these patients a heavier accuity to work with is because many of them come from the hospitals and still need a lot of very close supervision and care. For a number of reasons they just couldn't be discharged to their own homes. Probably the biggest problem you're going to see is that most of them are pretty wiped out and can't do a whole lot for themselves, at first. This is very typical of elderly people who have a major illness or surgery--it takes them longer to get back to their maximum level of functioning. Many of these patients are going to be getting physical therapy. Reason: PT and OT is one of the major qualifying factors that make a patient "skilled" for Medicare. The other big "skilled" qualifiers are IVs, sterile dressing changes and some continuous oxygen therapy. The major thing to be doing with these patients is to make them the first patients you see after report and check on any wounds they have or breathing problems. Make sure their treatments are getting done and documented. The other thing about them is you will often need to get in touch with the doctor to get changes in medications or treatments. You cannot wait a day or two to get those changes with these patient--it has to be done today. These patients have to have a complete nursing assessment done and charted at least once every 24 hours, so you and your colleagues need to figure out how to divide this responsbility among you. We used to have the night shift assess the people who were kind of out of it and awake a lot at night. We're talking about a head to toe written assessment. Insofar as your charting each shift on these patients, you want to aim your charting at what is making them "skilled". So, if they are "skilled" because of receiving physical therapy make sure you chart that they have had PT that day and what the nursing staff has been doing with regard to the patients ambulatory status ("walked to BR this shift with one assist--poor balance"). It they are "skilled" for oxygen therapy make sure you chart on their breathing pattern and what their breath sounds are q shift. If they are "skilled" for sterile dressing changes be very sure you are charting on the appearance of the wound including it's measurements and a good description of any drainage that is present.

One facility that I worked at had guidesheets on what absolutely needed to be charted on for each of the major reasons patients were classified as "skilled". Don't know what happened to them. However, if your DON and MDS nurse will let you guys know what the things are that are making each one of these patients "skilled", that will be your guideline as to what is most important to be documenting and attending to in these patients. Your MDS nurse will probably be your best resource person as he/she will be able to tell you what the qualifying reason is for the patient's stay being paid for by Medicare. Your MDS nurse might be able to get you some of the same information we had at my facility to help you with your documentation on these patients. The MDS nurse has to submit an MDS report to Medicare within 15 days of each patient's admission so he/she will know a lot about each of the Medicare patients. They will also know just how long each patient is on Medicare so keep in touch with the MDS nurse frequently to know who is on or going off Medicare. The minute a patient is off "skilled", medicare status, you don't, generally, have to do the same real specific charting required by Medicare. Also, have some way to flag these charts if these patients are being mixed in with your regular nursing homes patients so you will know just who is Medicare. Nothing will be more devastating to the facility than for them to realize that a Medicare patient didn't get the attention demanded by Medicare--they will not get their payment from Medicare and that hurts!

Of course, there will be other issues with them as well--the same old problems with incontinence, confusion, and on and on. Those are the things that landed them on your doorstep or else they'd be home getting home care nurses paid for by Medicare.

The reason LTC facilities like to take in Medicare patients is because of the money they are paid by Medicare. They receive a lump sum payment that covers all the services the patient is going to receive (PT, nursing care, meds). Of course, to save money, the facility is going to try not to have to increase it's nursing staff, have the pharmacy send generics, and utilize PT assistants. That's the way this goes all over the country. I don't envy the task ahead of you. I worked on a 14 bed Medicare unit in a nursing home along with a hall of 16 other regular nursing home patients and it was some of the hardest work I ever did.