fulzgold

My specialty is clinical reimbursement, MDS, for long term care. I have been working as an interim, using recruiters as my marketers basically. I invoice the company directly. My contracts start out for 8-12 weeks, however, there is so much work out there and not enough MDS Coordinators to fill those positions that some of my contracts run over that initial time frame. Some last just under a year. I have been really busy. I love this type (independent contracting) of work.

I have a Regional consultant that is absolutely brutal. Every time she comes to my building, she spends the entire time drilling me, insulting me and embarrassing me. She tries to get me to spar with her by insulting me first. She has a rebuttal for every possible answer I might respond with to any of her questions, or rather "Traps". The most recent visit, she spent 2 hours telling me I didn't know RUG categories, that I was dependent on my staff and rehab to achieve my case mix index, that she didn't know how I got the case mix I did, she called my staff in, asked them a few questions, and in front of them said, "She knows this better than you" "you are in serious trouble, I'll have to report this to the Administrator" And she did. I am an RN, I am RAC certified, I have been doing this since 1997. My resume is diverse, I'm an older girl and didn't get this far by being stupid. This broad is a better psychiatrist than the one that visits our building. I had to remind the admin, of my accomplishments in / for her building since I hired in and that I had maintained the current case mix above the budget. She had to stop and scratch her head, because she knew that was a fact, yet kept remembering the consultant's "warning". This consultant has done this same thing to me in the past. You can't argue or state your case, because you will be accused of being resistant-insubordinate-not in line with the plan...uggggh. Just Venting here. I know it's the same all over. Thanks for listening.

Ok,this is makeing me crazy. What do you do when family members google a med and insist this med is the cause of some S/E. Yes, by God, they've Googled the med, read the S/E, assessed the patient and noted the S/S and want that med discontinued! Sheesh! It must be nice to be sooooo smart, that all you have to do is Google, and "Eureka" you and you alone, have discovered the answer and none of the experts caught it!! DUDE! "We're not worthy" :bowingpur

My admin wants me to try an on call rotation for the staff nurses to keep the floor covered. I have worked in several types of nursing settings that used this solution, but that was years ago. Do you use this at your facility and how has it worked out. I know if I try to institute this, the nurses will have 10 fits. When I did on call as a staff nurse, we were to be available that day for the staff should there be a call off. If we got called, we were responsible for calling staff to get the shift covered. If we could not get it covered, we had to go in ourselves and work it, be it a nurse or cna who called off.

A prior admin I had, told my scheduler to cut staff back to one cna and one nurse on night shift without any knowledge of resident care needs. Over 60% of the residents were a 2 person assist, 4 residents who were behavior problems were also night owls, up roaming the halls wanting to have coffee, go out to smoke, asking for snacks etc, and an 80 yr old sundowner. The needs of the 2 person assist residents left the halls empty of staff for as long as 30 minutes at times, depending on what the only 2 staff members had to clean up in a room. One of the problem night owls with behaviors, convinced another night owl to leave the building at 3 am when staff were stuck in a room. Should I finish the story or can you guess how that turned out? Please listen to the DON when she says "that will not work". The DON is your eyes and ears. Your DON can tell you ahead of time if an idea to cut cost.... will end up costing more than what you saved in payroll. If you add up the cost of the fines, the new security system in your POC, etc.

No, there isn't such a place, there are numerous DNS out there who all had the same ignorant (not an insult,) thoughts going into it. You'll soon discover that doctors and nurses are not consulted about patient care needs, but told, by the non medical powers that be, what will and will not be allowed to be done for any patient. These are the people that hold the purse strings. I got so upset today, that I turned in a list of all the patient care needs and related sate codes, that have been unmet, to the interim power, who has screwed my patients royal, and I walked out of the building. All this without thoughts of myself, placing myself at risk of unemployment. Maybe I'm not so honorable, but stupid. Who knows. I love my residents, I know the difference between right and wrong, and I have to live with myself. Read some of capecod's posts for further education and training. Any DNS out there who can play the corporate game and still meet resident care needs is exceptionally intelligent. She may not even realize it.

This is a terrible job. You all have my admiration. I have met with so much resistance from "the powers that be". I'm fairly certain I was set up to fail. Back in April, after review of a referral, I had advised we could not meet this particular patient's needs. Marketing sends out a corporate wide email, " with the census low, we will have to work harder and put up with the more difficult patients" insult...slam....yada yada. Then regional shows up unannounced and holds a meeting on the new admission process which did not include the medical advice of the DON. Admin was to go directly to the referral source and accept the patient. No where in the process was the DON mentioned except to be provided with a typed summary from the admin, of the patient who was coming and what their needs were. I believe this change was and is against state rules. Anybody want to guess how that has worked out? I was not allowed to hold inservices because they didnt want to pay for it and they cut back on my staff hours. When we started to grow, I asked for more staff back and advised we were not meeting pt care needs. They said, give me a time study. OK, so we do one. Then I'm told "ok, write an add and we will put it in the paper". So I write it with HR input, give it to them. 3wks go by, every day in am meeting " gee, sure is odd no one is applying". Well, they never put the add in the paper. I dont live in the area and dont get their paper. I didnt think I should have to check and see if they actually did it. Now here we are, twice the census, same amount of staff, patients are angry, staff is crying, Medical director is upset, not at me, he says he'll quit. We are in our state window and everything's a mess. I am done with this garbage. Its only a matter of time before it implodes. I'll never put myself in that kind of position again. Lesson learned. I'm an idiot, 2 thumbs up, to all you tough DONs out there.:heartbeat

I got lucky at my facility. The Rehab was an SLP with a head for business. I showed him the case mix index and explained how the nursing care, and therapy tx effects RUGS. I gave him the list of rugs with $ amounts and a list of requirements for achieving the same. He loved it. Pretty soon he was asking me for a list of residents and current rugs. I gave him the rules on date setting for the different assessment types and started letting him set the dates. He always worked with me and understood if I lost a higher nursing RUG by using a therapy date that took skilled nursing out of the look back period, then he would have to use minutes for the date I needed. The date setting was a mutual effort. Our case mix has been really good. Too good, now corporate sent him to another sister facility to help them out. He says he misses our team work. The team at his new facility is resistant and tempermental. Nursing doesn't talk to therapy, therapy doesnt see the need to talk to nursing, MDS C. refuses to consider team input on the MDS schedule and sets it in cement. They all know the rules, they just don't see the end results of pooling talent. Shame. Our new rehab is only a COTA with a BA in something else. she's real nice, I hope it works out. I'll have to train her too. Sheesh!!!

Wow, good ideas. Thank you so much. The prior DON had an assistant who did everything for the staff nurses for so long that they have forgotten their job tasks. They truley think it's not their job to finish an order or do their own admissions. I gave one nurse specific, one on one, instruction on a new order on a friday. On Monday I discovered she never bothered to complete it, and stuck it in a pile of "to be filed" papers. I have inserviced and encouraged till I'm blue. Had to write her up for not following policy and procedure. Not just once, but a second time as well, with final warning. That seemed to be effective. I have assigned specific nurses to do tracking such as an RN for wounds and infection control, the rest are lpns assigned to wts,NAR, MAR/TAR and MD orders review, Falls/incidents and Certain sections of the MDS related to the specific tracking each does for starters. I am the MDS coordinator and do the careplans and restorative. We recently had to give up our restorative aid and will be inservicing the other CNAs to pick that up. I appreciate your advice and will alter my task lists. Right, there is only 25 res. so once everything is organized it should'nt be hard at all. Thanks again!

I'm a new DON in a small facility, less than 25 res.. 14 yrs of SNF experience:ADON,MDS Coordinator, staff nurse... I was not inserviced of course, given a list of tasks to sign and tossed the keys. I'm told this is the norm. Anyway, I'm a detail oriented, and have good time management skills, but find myself spending the day reacting to all the daily pop up stuff. Reacting, is making me crazy! I have no ADON or MDS nurse, not enough residents to finacially support those positions. How do you manage to "get it done" do you make yourself a dly list or set out blocks of time for certain things?

Jeesh! Our admin does stupid stuff like that too. One time she drove 2 hrs away to a womans apartment to assess her for placement. When she came back she was actually considering this patient. The patient was a 42 yr old female who had lived in her bed for the past 3 years. Morbidly obese, wasn't sure how much she weighed or how she would even get to our facility. Admin thought she could just come in a car!!! I said, Uh..No... First of all, she might die if you move her, she has not left her bed because she can't stand much less fit through the door. You'll have to hire an ambulance to bring her here and she may not make the trip. You'll have to rent or buy a bariatric bed as well as numerous other bariatric DME. And, someone at home can have their entire life built up on shelves surrounding the bed within reach, but we can't do that in a facility. Our admin will take just about anybody. She'll even promise them a private room and then when their medicare days are up they won't move and she won't make them move. So there goes our medicare suits. We have spent more money on some of our patients she took than it was worth. I'm pretty sure she doesn't cost anybody out. She is always willing to take people with no or pending payor sources.

Our is Twonumbnutsinacan. Still having all kinds of glitches. It won't validate because no matter what assessment you code for it throws old answers from prior 2.0 admits in there and fatal errors it. Can't transmit till they fix it. If they don't get it together, we'll end up in a default rate for numerous files. All that work for nothing.

In August, I moved all the routine OBRA assessments due in october, up to September and spread them out through the month. That was rough, but that way we have plenty of time to focus on the PPS. We are choosing the no option. We will be doing repeat assessments in 3.0 version for any PPS who's payment was split between September and October. I'm glad we did it that way for now. My RAI manual is still not here yet, had to download one from CMS. My SS person had refused to attend any seminars and now says "I'm not doing this". Sheesh! Other team members have taken it pretty well. We are trying to change over some of our assessments to reflect the 3.0 items, that's not done yet. CNA's still need inserviced on ADL grids, Admin turned in his resignation!! AAAAnd, it's monthly change overs!. It's too much to do and not enough time. I've been putting in 12 hour days for over 2 weeks and 3.0 hasn't really started yet.

Too many,, and too many!

Anyone ever have a mutiny at their facility? One shift of CNAs against another? What did you do to stop it?

[ You can't teach common sense . No, you can't. Common sense isn't all that common. It is actually a gift. I've heard these questions from staff: "Since the resident fell at the hospital and not here, do we still have to do neuro checks"? Concerning a resident on 15 minute checks: "But family wants to take her on LOA, what do we do about the 15 minute checks"? Or 3 hours into 2nd shift, a CNA wants to report they just found So and So "full of sh*t and I'm tired of first shift leaving that for me to clean up".

Ever had to or tried to discharge a patient who does not want to leave? Been lucky so far, but we have had a few who were either not sick enough to qualify with their payor source and did things like " fall.. then say .."can I stay now?" or refuse to leave and refuse to pay and demand all sorts of care they don't need. I read an article where this hospital, I don't remeber where it was, had a female patient that had been living there for 18 months because no one ( LTC) would take her and the hospital could not legally discharge her. She had cost them 100s of thousands of dollars. What are some of your experiences with this issue.

We dont do those any more. We instituted a "weekly assessment". It covers everything that the MDS covers and encourages the nurses to provide a routine full assessment of residents who normally would not get one unless they are sick or it is time for a quarterly. The assessments are scheduled by room number and only takes grabbing a set of vitals and moments to fill out. It also serves as the nurses notes for that shift. at first the nurses hated it, but now they love it. It is actually less paperwork and catches health problems early on, that otherwise may have gone unnoticed until it was exacerbated and painfully obvious. It resulted in a good learning tool for the new nurses, and led them through a head to toe assessment. It's also nice for any one who is doing MDS or other information tracking. No need to make up a documentation schedule. Its already in the chart with the weekly in place. It tracks weights, nutrition / fluid intake, continence, infections, behaviors, cognition, ADL abilities, related meds, etc. All in a "check the box / fill in the blank / provide an example/ format". State examiners thought it was a pretty sharp assessment tool.

I wouldn't say "better" than. I have experienced the same ungracious comments from insecure LPNs. It's not in my character to pay them back with comments in kind. Remember, the difference between LPN and RN is simply 6 more classes and 2 more semesters and limited clinical seats are given to highest GPA first. Very competative. The state exam is not the same for both. That's the way it used to be any way.

I may be a little to picky about accuracy in coding but, I scheduled a Sig Chng on a res with End Stage Alzheimers who went hospice. She can no longer speak anything but gibberish, screams, hits, bites, kicks during care, stopped eating and drinking. 2 Staff perform her care while she beats them up and screams, they bring her out of her room all dressed and walk her down the hall. She is agitated. On rare occasion she will take a cookie if you catch her at the right time, but you don't know when that will be. certainly not enough intake to sustain life for long. Her facial expression is frozen in a look of pure fright, ( distressed). MD says at this stage, they don't actually experience hunger and thirst. All documentation is in place except for SS. SS never sees this woman, the rest of us hear her screams during routine cares throughout the day. SS goes in res room with a cookie in her hand, holds it up and says look at me. Res grabs the cookie and takes a bite then stuffs it under the covers. SS codes res for 2-Moderate impairment, because SS saw that as " making a decision." SS used NN to make her MDS documentation, and it supports a 3 Severe impairment, but SS sees the information as a 2. Now I am an RN, my medical training tells me this as a "severe cognitive impairment". I was under the impression the MDS Coordinator made the final call on codeing. SS hands in code for 2, I chose to code a 3 supported by the chart. Now I've been acused of "upcoding for money" and you name it, I'm just a delinquent. I was also under the impression that once a res codes in an Impaired cognition rug, the level of impairment 1-2-or 3,doesn't matter ( moneywise ), there is a set price for that. So what do you do? Go for accuracy and matching the record or grit your teeth and enter what the other disciplines code. By the way, My Activites Dir. fills out her section the exact same way for all residents. Its histerical. I mean we got blind people playing Bingo! board games!, and all sorts of neat stuff.> Well on paper anyway.

Not really, boobs don't have the education required to understand the questions. Any of them who want to argue, just tell them the difference is 2 more years of college and 8 more classes.

Has anyone ever had the hospital fill out your paperwork for an admission? I have often considered requiring this. We normally get orders faxed early on so we can get a head start on the paperwork and hope to only have to clarify order changes after the patient arrives. We don't order meds till the patient is in the building. Then they come in with the original orders, paperwork different than what was faxed, and the doctor has made med changes. So then you have 2 sets of admission orders, each one different from the other, and you still find yourself scouring both sets of orders looking for differences to clarify. Lots of things get missed this way. I hate it. Sometimes the MD will scribble a change at last minute in the margin on one of the papers that takes 4 nurses to decifer. I wondered if it wouldn't be easier to have a basic, reader friendly, Facility Admission Order. Fax the hospital this form and say fill it out. I would think they'd be happy to if they want to get rid of the patient.

Right.

There are many situations where there may be more than 3 quarterlies re: adding the OMRA and OSRA when needed. Since they have no specific OMRA/OSRA assessment, one would use a quarterly. Now when 3.0 is in effect, a lot will change.

My consultant says the quarterlies can not be any further apart than 92 days but can be closer together. So if you have a res due for a Q in a month and notice right now they had a PICC line put in for IV ATB for 10 days, then you should do a quick quarterly to capture all that work. Otherwise you have to eat the cost.