katoline

Wow. I have been a nurse for 28 years. This argument has been going on this long at least. I am on here today after moving to Texas and checking the Nurse Practice Act myself about just these issues. Making Assignments The LVN's duty to patient safety when making assignments to others is to take into consideration the education, training, skill, competence and physical and emotional ability of the persons to whom the assignments are made. 11 12 If the LVN makes assignments to another LVN or UAP, he or she is responsible for reasonable and prudent decisions regarding those assignments. It is not appropriate and is beyond the scope of practice for a LVN to supervise the nursing practice of a RN. However, in certain settings, i.e.: nursing homes, LVNs may expand their scope of practice through experience, skill and continuing education to include supervising the practice of other LVNs, under the oversight of a RN or another appropriate clinical supervisor. The supervising LVN may have to directly observe and evaluate the nursing care provided depending on the LVN's skills and competence, patient conditions and emergent situations. Timely and readily available communication between the supervising LVN and the clinical supervisor is essential to provide safe and effective nursing care. - from the Texas Nurse Practice Act. Has nothing to do with 'the alphabet' or years of 'experience', it is the scope of practice. In certain circumstances and Lvn/Lpn can supervise and evaluate the care given by another Lvn/Lpn. Anyone with experience can give 'guidance' or 'words of wisdom' to another. An experienced nurse might suggest to a new MD or Advanced Practice Nurse that perhaps 'such and such'? It's all about approach, respect, and the common goal of best outcome for the patient. Often a CNA notices something about a patient because of their hands on care, that a nurse or even an MD might not. With things going the way they have been in health care for a long time now, more and more practitioners with less 'formal' education will find themselves in charge. The Assistant Therapist as the department manager, with the Licensed Therapist doing the evaluation and writing the plan of care. The Lvn Unit Manager or ADON as department managers, an RN might be needed for a 'comprehensive' patient assessment and initial plan of nursing care. I guess what bothers me at times is more of a 'control' issue and not a team approach. One DON I knew once said 'we (nurses) tell doctors what to do'. That was just so wrong. But often case managers do go over charts and leave MDs notes on what to chart about, what tests need to be run or questions about where things are headed. It's all about reimbursement, what is covered and what is not and in the best interest of the patient to get where they need to go by going about it in the manner required by insurance and/or Medicare and Medicaid guidelines. Not saying I agree with it. I have found myself on the phone with insurance companies about certification actually crying because of some denial and asking 'what if this were your mother??' And the Doctors are left shaking their heads. katoline

So mlbluvr, did you start this thread? Is it a trick question? who signs and attests to the assessments being complete? 50 PPS huh, hmmm. are you a mole? just wondering.

I know this is a month later, but things that might skill a palliative care patient could be things like pain management, respiratory support, suctioning, checking O2 sats and they may even be on chemo or radiation for palliative reasons, to shrink or help keep a tumor from growing and pressing on or blocking off other vital organs. Therapy might assist with pain management, tens unit, heat packs. Just a thought.

Very scary all. This is another take. I didn't even have a facebook acct. but several people at work did. There are always cliques at work. I 'shared' an office with a coworker who had taken over the office with not only her own things, but that of another employee (relative) sort of as storage. I came after her, but in reality, was the 'dept head' being an RN, she an Lvn. There were plenty of cabinets and drawers, but they needed cleaning out, snacks, decorations, trash. I had one drawer and a double cabinet. We were going to have a life safely inspection and I was told to get things off the floor. We had bankers boxes, those kind we often use to hold things we need to keep until yearly inspection or if files, three years. But the fact that our files were in boxes on the floor and another dept's supplies were in cabinets just hit me wrong I guess. The Lvn was on vacation. I asked my immediate supervisor and another district advisor about going through things and they were all for it. Someone at the facility who didn't like this Lvn posted I don't know what, but a family member of the Lvn. would go on facebook, knew this person and it got back to her. All while she was on vacation. I knew something was up when she came back mad and barely spoke to me. And yes, I did try to call her and let her know I needed to go through things, but wasn't able to get up with her. Then I thought, 'why should I bother her with this while she is on vacation?'. I never found out who posted, the supervisors who encouraged me acted as though they knew nothing about it. It was a mess and things were never really comfortable afterward. This was a case of someone being spiteful. Shame.

Dear Blessed, you are you know. It may be hard the way things ended, but if they hadn't with your intelligence, conscientiousness, and strong feelings to make things right, you would have burned out or hardened. Please don't do that. Just from reading what little bit you have stated you are heading for a great career if you want it. DON, Admin. you name it. First of all, Do Not Write anything. If you have personal nursing insurance you can call and get advice. You're not accused of anything, but they have advisers in these matters. If you don't have insurance of your own, I suggest you get some first of all, but if you know anyone in another company higher up the chain who you feel comfortable talking with, you might get their opinion. A risk mgmt. person would be helpful. Anything you might write would not help you. As I said, you're not accused of anything or you wouldn't have been asked to leave. The company's risk mgmt. would have gotten involved with you, the facility etc. But don't think if they had, even if they acted like they are trying to help, they represent the company. The company will place blame on an individual rather than face something systemic which is what happened. But if they could have challenged a tag, they would have. Anything that happens outside of your shift or prior to you assignment has nothing to do with you. You did a great job of thinking critically. You see the whole picture, the whole person, not just your task to fill in a box. Next time make sure you get your work done, then if you see things that need to be fixed, share that with whomever you need to and set things right if it's within your scope and your job description. If you mention something to so and so and nothing gets done, use your chain of command and mention to that person. Not in a threatening or derogatory way, just that this is what you think and ask them what they think. I was once told to keep a notebook. I felt if I needed to keep a notebook, I needed to find another job. Unfortunately a lot of the 'care' just isn't in some employees. I don't understand it and I hope I never do, why go into the 'caring for people field' if you have other agendas? Just one more thing, as I said, you are truly excellent and will go far, but don't take on too much. You'll get plenty of responsibility further down the road. Many will take advantage if you let them. And it will become expected of you, but if your work isn't just right don't think you'll get help there. You owe the administrator nothing. The tune has changed because things are starting to hit the fan, where was the admin. when you were upset because you were being walked out the door? BTW have you ever considered MDS? Just a thought.

Well, went in Monday, computers down again. Good time to catch up the Medicare book with admissions since Friday (5). I have heard that other facilities, at least Kindred where I worked before had a case manager who really Coordinated the tasks to be done. There is a lot to oversee. When the computers came back up just before lunch, I get an email saying all the assessments for month end close weren't done, I need to do three short assessments, a 5 day readmit and a new 5 day comprehensive assessment before the day is done. I couldn't believe it. It was cc to the administrator and she forwarded to me and asked me to let her know how things were. Month end was supposed to be over, that's why the big rush on Fri. Unfortunately, I emailed back that I felt there was a communication problem. I was told on Friday all the assessments would be completed, to just relax and start fresh. (I had offered to come in again on a weekend - I'm salaried, so no overtime for them. I just asked to take Mon off if I came in) I was told this by three people, the Admin., the DON and my coworker. Why go thru everyone else to tell me something and give a lame excuse such as email down, well how did the corporate person get up with the other three people? I completed the short assessments, then the 5 day readmit. It was almost 5 pm when I started on the comprehensive. After putting in the required information I realized the activities director did not do her section. this was maybe 6 or 6:30. nothing i can do. After interviewing the resident, who has a terminal illness, she was exhausted. There was no way I would wake her to ask activity questions. In this MDS computer program, you can get to the Caas without closing the assessment, so I completed them. I emailed everyone with cc to everyone what I had done and went home exhausted myself. It was almost 8 pm. I go in before everyone and leave after everyone. I'm working the same shift as the 12 hr nurses. After just three weeks, I'm thinking maybe this isn't the position I thought it would be. Makes me sad, but I've got to do a reality check. Oh, and I've never worked in a facilty where the floor nurses input any data on the MDS. In fact, the MDS depts. did the quarterly nurses risk assessments. And rarely does anyone else put anything on a careplan. I'm just given notes, emails or spoken to in the hall that such and such needs to go on the care plan.

My coworker does my discharges, other than that she stays to herself and has nothing to do with "this side over here". it seems that others are disappointed in my ability to handle the workload or manage my time. i wasn't even shown how assessments are completed here, how to do the caas or even how to get in to the care plans. i guess with my experience i was expected to just come in and run with things. well i have to the best of my ability, but if i wanted help, to make someone feel welcome and a part of the team, i don't think i would have done things this way. i have noticed that there are three in admissions, two in social services, an SDC nurse, ADON and DON. they had a wound nurse, but are looking for another. there is a receptionist and as far as i can tell the nursing staff is on each of the two ends with 62 residents, two nurses, two med techs, a nurse manager beside the CNAs. looks like it's well staffed everywhere but our department. so that's how it is over here. someone did end up coming in to do assessments at the end of the month. we'll see how things go next month. katoline

After leaving Eastern North Carolina for the Great State of Texas (it's a whole nother country - i was going to get that license plate, next time when i can order online and not wait two hours in a line) i have started my position as MDS Coordinator of a beautiful nearly new (2 ys) luxurious facility only five miles from where I am staying. This is the fourth facility i have worked at, it is for profit, two of the other three were as well. There are 125 beds all full. 75 certified medicaid. where i had worked previously all the beds were duelly coded. We have approx. 40 medicare/managed care residents the rest are medicaid, private, hospice. We admitted 42 medicare residents this month, that doesn't include the few private pay that are not PPS. We discharged about the same. I believe the average PPS length of stay is 25-30 days. Thats a whole lot of five day admission assessments. Not to mention keeping up with the medicare book, schedules, certs and doing diagnosis codes on the admissions. There is daily stand up, weekly mcr meeting, an IDT meeting which is basically a delivery of care meeting of all the admissions since the previous meeting which is counted as a care plan meeting of sorts. They usually last 30 min. a piece. Last week we were scheduled from 10 am after morning meeting until 3:30 pm without a lunch break. Very informative, help with the assessment and for care planning not to mention being able to get things off on the right foot or correct an issue before the resident has been there very long. We have no data entry person. I haven't had a data entry person at any of the facilities i've worked at. the charts here are electronic. it sounds great at first, that you could find the information you want without having to travel the building or worry about waiting for a chart. but electronic charting is only as good as the information entered. there is never a complete ADL sheet to pull, ever. usually the are filled out less than half. i now have access to another program so i can get the therapy evals without having to ask therapy. i guess i like a paper chart that i can put my hands on and say "there it is" "there is the answer to my question". this way, not so much. there may or may not be a nurses note. usually they are just like checking a box on a form, but no added information. it's very difficult to tell if a person has had a fall. sometimes there will be a note, but not always. someone with the admission assessment may say there is a stage I or skin tear, then it can't be found later on the treatment cart or skin sheets. of course no order. usually the weights aren't to be found. often there isn't a diet order. if the dietician comes in before my ARD, i'm lucky and can read what she might have suggested. the dietary manger doesn't even have access to the program, so i've inherited sections K & L. the social worker here does B & C, which is new to me, along with D and Q and activities does her section F. Coming from NC and having Myer and Stauffer CPA llc. for CMS mcr and mcd audit yearly, along with taking the yearly training. I have it drilled into me that you MUST have documenation to back all your answers. I could write or enter a note I suppose, but i'd need to do it on every subject. Even that wouldn't support the entire look back or even three occurances. We have weekly dining room duty, daily MAR, TAR and skin sheet checks and maneger on duty weekends maybe once every 6 to 8 wks. I was given a stack of MARs to check for the end of month and i wasn't able to fit that in. I was also to look over each and every possible admission, state my concerns and come up with dx codes whether they were to be admitted or not, this can be six to eight a day. i no longer do that. i just come up with the codes. I've been here now just 3 full weeks and have worked two out of three weekends to try to catch things up. I was given a few "days" of training that lasted maybe five or six hours, usually less, and instructed on the computer program, i was just exposed really. the computer freezes up regularly and when i ask for help, i've been told help will be there. i'm still waiting.

Are you talking about Medicare or case-mix care plan meetings? With medicare, our social worker usually scheduled the care plan meeting the week after the 14 day ARD so they would fall around that 21 day requirement (7 days after the 14 day deadline for an admission). We had care planning one day a week, so it might be a few days either way. If a family wished to have a meeting prior, we included our care plans with that, had them sign the attendence record. With case-mix, I would get with the social worker for the upcoming assessments due. I would usually have them split in a managable way a few weeks or so before they were due. We often have to "capture" part B rehab, IV fluids or ABT, etc., before we had those residents scheduled, so if the letters had already gone out or the number was high, we would try to fit them in as soon as we could. We were told we could not move them up in the schedule more than a month unless they were a significant change, so they would be due for a care plan soon anyway. If something is going on, family would often like to discuss it and we could have an impromtu meeting on a day that was not a regular care plan day. Hope that helps. Everyone does things differently.

I really think that delegation of duties and who actually does what varies from building to building, company to company. Where I work, I do 90% of the MDS and usually all the CAAs. Everyone is always busy. Staffing is always less than ideal. In all my years of MDS, just this past year I started going entirely case mix. With everything going on with the changes, it wasn't that hard to give up PPS. Doing case mix has made me see things in a different light though. Our charts have stickers for MCR (we use them for mgd care as well). The floor nurses are in tune to look for those and usually chart fairly well. Other areas like the rehab depart, SW notes etc are good sources for me when doing PPS. For case mix we make out lists ahead of schedule as to what date which resident is having an assessment done, but honestly with the Mcr/Mcd reimbursment changes it's all anyone can do to do the minimum. We had layoffs, pay cuts, layoffs again and again. (I was actually part of the last tier of layoffs.) Then of course something comes up and an assessment has to be added and another postponed. For case mix, I had to do quarterly nursing assessments on each of the residents I was working on which consisted of Brayden scale, fall risk, transfers, bowel and bladder, pain, all psychotropics for consent for present dose, aims if needed, smoking if needed as well and restraints, but we didn't have any in the building. I gleaned the chart for changes etc, interviewed the resident and usually because of time constraints, if anyone's part wasn't done, i would do it. More times than not I was doing it. I didn't mind if it was something that I came across anyway or could find easily, but I hated having to interview the resident for mood. After all my interviews and data input (or before) I had to write a lengthy nurses note that covered each of the items that there was no documentation for, such as behaviors, seat cushions and pressure reducing mattresses, the results of the restorative nursing, any changes in adls or any temporary condition that might cause a temporary change and not a significant one. Very often, unfortunately, I would come across something that was missed. Perhaps something as simple as MD needing to be notified of recent blood sugars and current insulin or oral hypoglycemic doses. It might be something I saw during my interview that needed further assessing and follow up or even sometimes hospitalization. Labs were not put in the chart regularly,or were kept in a different place until filed and all x-rays, MRIs, CT Scans, I called the hospital for a copy to put on the chart. The same with hospital discharges or notes from an ER visit or dialysis notes. It could even be an order written that no one took off. I took it upon myself to pitch in with these things because I am the patient advocate. I am supposed to be his champion. The nurses love the patients and follow up as best they can, but we seem to be more interested in filling in a square, signing off on some lame "inservice sheet" that someone just made up because of something that happened or going to more and more meetings to see that we are doing our job and catching things. And most facilities I've worked at the residents have so many medications. They are coming in sicker with poor prognoses and nutritional intake just waiting to become pressure ulcer candidates. Or they may be bariatric patients with personality disorders and demanding demeanors. whew! Well.... I guess we all know we are in a mess and in this together. I enjoy working. I'll do almost anything as long as it's ethical and in my scope of practice and I feel it's in the best interest of the resident. But like everyone else, my time is limited. I have deadlines. Who do I perfer to get mad at me? Why do I have to ask this question? If I'm salaried and work way way over 40 hrs, I put off my own appts., MD, dentist. If I'm on the clock, I can't get overtime. We need clones. I read where one of the CEOs (won't mention any names) in his quarterly report to the board and stock holders "we're cutting back all we can and nurses won't work for pauper pay you know" No, but now we get the privledge of doing the work of two people. By the way Cape Cod Mermaid, what is your position now? Are you DON? Katoline

noc4senuf, where are you located? i wanna go there! maybe you should become a consultant and get things started in the right direction!!!

we have a medication toxicity careplan. i think maybe meds like depakote, klonopin should be careplanned there. it covers dig, coumadin, lasix some others. then have a seperate behavior careplan.

no, klonopin is one of those meds like depakote that's used for mood/behavior. it's an antiseizure medication. sounds like a sedative or antianxiety because clonazepam (it's generic name) sounds like lorazepam (ativan) they are both benzodiazepines. what the heck's the difference? i don't know. reading the drug book now and ativan is used for status epilepticus like valium is. must be some cross over. side effects of one useful for something else. i've given and taken a lot of meds over the years, i remember the ones i personally muddled thru the most.

I was taught that a careplan is a work in progress. I often do the careplans as i am working on the CAAs simply because i work on so many and often at once, i need to do them while fresh in my mind. if things change the day we actually go to careplan or anytime for that matter, we update. we constantly update careplans in our falls, weights and wounds meetings or in stand up if a change of condition occurred. When you sign the caas you're signing that they were completed and worked and a decision was made to proceed or not, not that the careplan was completed. you still have seven days from the decision to proceed to do them. careplanning an expectation of a rehab patient is a great goal. we look at the therapy notes and evals, they have them there and they are the ones we work toward. we don't do a significant change on rehab patients that are improving, they are hopefully going to do that and it may or may not be gradual. what we were told to do a sig change on is if a long term care resident say falls and breaks a hip, returns on therapy and improves to the point they were at before the fall. they were probably made a significant change when they returned post surgery as well. only if someone fx a hip that doesn't get out of bed anyway, continues to be total care and doesn't decline in any other areas would we perhaps not do one. if they are bedridden before, they probably aren't going to get rehab unless short term for positioning or such. same goes for bed/chair bound new tube feeding. may not be necessary, but if they come back medicare, we'll be doing new assessments anyway.

:)PNWB, what is the DQA website? I feel that the reason for the medication should be careplanned as well as the medication itself. I think there should be behavior sheets on the MAR if appropriate as well. What i am confused about is our quarterly ancillary assessments. Klonopin and depakote aren't psychotropics, probably should still be monitored as any potentially harmful drug if potential for toxicity, but labs levels may be different for psych purposes than for seizures, at least that's what a psychiatrist told me. Maybe i should ask our geriatric pharmacist that comes in. thanks for all the input

A family will never get upset if you send their loved one to the ER out of concern (unless an obvious DNR). Better have, DON, MD mad than have family sue. It's your license. Especially if the family wants them sent out. Our medical director gave us a list of things that can wait until morning, a fall with no injury, a non-critical lab, low grade temp, one episode of vomiting. you get the idea. our medical director is our back up for all the residents. have all back ground diagnoses ready and chart open, with vs and other pertinent information. it's up to him to get with the non-responder. beware also of the "sleep talker". we had one of those and you should know what it is you expect from the doc and if the answer is way off base, question it, several times if necessary. if still not what you expect again go to your medical director, NHA, DON and as everyone says document document document.

Thanks! What about consent forms? I've only been doing AIMS on antipsychotics since side effects for antidepressants and antianxiety meds don't include PS or TD. The same for anticonvulscants. I have recently been adding medication toxicity careplans on many of these meds since our pharmacist recommended for Black Box Warnings.

Get to know your residents as people and LOVE them. Once you learn them, it's easier to see subtle changes. Get to know their families, they are sometimes difficult, but often there is a reason, like they feel guilty they can't care for their family member. If they come often, greet them, try to remember some little thing their family member did recently. Realize you can't please everyone. Some residents are demanding because they feel they have lost all control of their lives, some are afraid, especially if they are new. Be supportive, give them hugs, but don't baby them, they are adults and deserve our respect. Most of all, LOVE THEM! They could be your family member and I always like to think if I wasn't able to be with my loved one, that someone like me was taking care of them. :hug:

I have a question. Even though I've been doing this for a while, each facility does things differently. Is there a CMS rule for this? i realize that a medication is what it is, no matter the purpose. That said, depekote for mood stabilization is not counted as a antipsychotic or antidepressant. Likewise trazadone if used prn (some docs still use it that way) at HS for sleep is still an antidepressant not a sedative. How do you careplan these? Do you have to do quarterly ancillary assessments? if so, how is that handled? i've seen in the chart where family consent is obtained for meds like depekote and klonopin. I understand where behavior sheets are needed if that is their purpose, but do you handle the medication and the purpose seperately? a mood/behavior careplan, but not a psychotropic?

I would say it's multifactorial, depending on age, size, weight, general health of the person. Not to mention what other medications they might take, the reason they are taking it and how long they have been taking it. Being a polypharm myself, i'm 54 about 5'7'' 170 lbs and can take up to 4mg/day if needed. If taken before bed, i'm drowsy in the morning. If taken during the day, i may need it to stay on an even keel due to stress or circumstances. It might calm me down, but not knock me out by any means. I usually take 2mg/day in 4 divided doses, nearly every day. If they had an imoticon for a horses mouth, i would pick it. LOL!

:saint:Oh NotFlo, I'm sorry to say, i believe you may work for the same company i do. too many similarities. Love the people i work with and the residents, but i have to wonder when is the line drawn where some top execs have to say to shareholders, we are in the people business and these people are our parents, grandparents and neighbors. maybe they truely don't know what it is like on the front line and need to come on down. until things effect us personally, it's sometimes hard to relate. we've all got to answer to someone in the end, i just hope i'm able to pass thru the gate.

I came across this before i left for work this am. Oh ug! What next? WASHINGTON - As the deficit reduction supercommittee hunts for $1.5 trillion in additional savings, US hospital executives are so worried about having their payments cut that they plan to start lobbying Congress next week to shift the burden onto their elderly patients - specifically by raising the age of eligibility for Medicare. The American Hospital Association is rallying hundreds of hospital leaders to descend upon the Capitol on Tuesday and urge legislators to consider increasing the Medicare eligibility age from 65 to 67 as one way to save money without reducing payments to hospitals. That move is so controversial that President Obama, who once expressed a willingness to entertain the change in Medicare age eligibility, omitted it from his deficit-reduction proposal last week.

Not to get too specific to include Company names, but was wondering what the atmosphere is in general about mcr/mcd cuts and what it is doing to long term care. How specifically is your facility effected? Are you seeing staffing cuts, supplies, dept. budgets, or being asked to take a salary cut? Are you seeing a direct effect on patient care?

AANAC is great for recogniton, networking, new information and CEUs required. They post positions online and send you offers by mail. I just got recertified for 3.0 last fall and took online classes. I wish I had purchased the modules for printout or manuals, but with all the changes it probably doesn't make sense. I say go for it. You can do a module or two at a time when you have the inclanation. It also clarifies some things better for me and it's at your own pace. Good luck! sps (posted previously, but just as pertinant) we need you.

i do not feel like a nurse. no critcal thinking skills, if a res is sick we ship 'em to hospital i agree with no restraints and pt rights etc. but i'm losing my skills. because of paper work and the fact when a res is sick we ship em out. ltc may not be for me d/t paper work, no critcal thinking, losing my skills, no iv's, etc. any one in ltc have any advice. polly, i think you may have answered your own question. go where you are happy. ltc is not for everyone. we each have our own nitch and i'm so glad we do. i'd hope to see you when i needed you at the hospital.