debRN0417

I have seen LPN's who are Unit Managers and RN's working the floor as the "charge nurse". It sounds weird, but in that case the Unit Manager was "in charge of the unit duites" but the RN was "in charge of the unit"...clear as mud???? The RN preferred the direct hands on care and did not want the unit manager duties. The LPN was not "supervising" the RN, the RN basically reported to the ADON, and the LPN reported to the RN and they really consulted each other ....it sounds crazy but it worked. However, that being said to satisfy the legalities of the whole thing...the LPN was actually the one who knew everything that was going on and exactly what to do about everything ( all the unit manager stuff and a great deal about the residents). The RN was very knowledgeable and professional as well but was really only part-time,and the LPN was better at "being in the charge capacity" because she had been there 100 years and ran a tight ship. The RN would do the assessments, though, and they both worked together to take care of their residents and had a great unit.

I agree with CCM- if the resident/patient is requesting medications before they're due, then the MD needs to know to reassess.

The area on aging in my "area" would have referred this to us and we would have investigated...I have never heard of them "citing" like that, but I guess its because its a different state??? We receive all kinds of F.Y.I's as we call them, from the ombudsman and adult protective services and we look at them on surveys but they are usually unsubstantiated little things.... If you were following the care plan then what is the neglect issue? Forgive me, I know we all agree on that I am just confused. I am not understanding this agency's authority to specifically cite a person or facility. In my state we are the ones with the enforcement authority and anything like that would have been referred to us for further investigation if they thought there was a problem.....I would appreciate any information that would enlighten me.

It is all how you say it. You have to be honest and thorough in your charting and not leave out pertinent details, however, how about "Resident found without O2- list sats- document starting the O2 and at what rate-document your full assessment of the resident and that you notified the MD and RP. Why would you even document that you found a wound without a dressing? I mean if you have orders for it and unless you assess the wound and there is a change from the last time, then would you just not replace the dressing and document "dressing replaced to wound" and whatever else you need to say. Dressings come off all the time. If you have reason to believe someone was not doing their dressings then you should speak with the DON. Blood pressure ___/___. Document what you did . If it was circled on the MAR that the med was not given and an explanation written why it was not administered at the time, then it is not your butt that would be in a lurch unless you were the nurse who did not have the med available and did not notify the doctor and did not call the pharmacy for a STAT delivery. I would fill out an unusual occurrence report and notify the DON. I understand your feeling like you need to cover your butt, but if you were not on duty when it happened, then you would not be questioned, however if your signature is at the end of a note like that, you will be the first in line to be interviewed about it....

love it!

Just be careful. Make sure you look at the labor laws, I mean if you are requiring someone to be on call and stay near the phone or being available, what are the laws concerning this where you work? They may have the right for some type of reimbursement regarding the on-call status whether or not they are called in to work. I ran into this once and we had to start offering an on-call rate which became a total nightmare....I think it turned out to be $25.00 for being on call for each 8 hour shift. We then had to change it to 12 hour shifts because it was costing us a tidy little sum... If you are not paying them or have some type of contractual agreement as far as being required to take call then they do not have to be available. Salaried persons are exempt from this I think because it is usually in the agreement for a salaried position. Just check. You dont want to end up in some labor fight down the road. Oh yeah, the staff got the 25.00 for being on call plus whatever their rate was when they had to come in to work...then there was overtime...ugh....but sometimes you have to bite the bullett.

That's the problem with alarms of all types...too many alarms...not enough nurses. After a while you tune them out. It is frustrating.

Thank you CCM. I appreciate that. I just try to live in the real world....

If they are "physician ordered" suppliments they could come under scrutiny by the DHP regarding calories, additives--yada yada..but if they are something that you are doing for "snack" or "pleasure foods" then all you need to do is make sure that whatever ingredients are used are appropriately stored, dated and labeled when opened and that they are discarded after whatever your use by date is. Your dietary department should have guidelines as to what their storage regulations are. Staff should wear hairnets when preparing and of course use other good hygenic practices, handwashing and cleaning of blenders and whatever is used. We should not get all twisted up and bent out of shape over offering our residents a snack or pleasure food. Like it was said in other posts, when you are home you graze whenever you want and mix up all sorts of concoctions to eat or drink. Home-make smoothies and milkshakes are so much more tasty and more readily accepted. You just have to make sure you are monitoring the fridge temps, and storing, dating and labeling all your stuf that you keep and use. I have seen ice cream parlors and snack bars in some facilities that are used daily but I think the kitchen staff directed those. We never "inspected" those during the survey but the local health department might have. I don't know and frankly I wasn't really concerned about it because the residents loved them and were having such a good time and very excited about it...so if it's not broken, why mess with it?

Office of the Attorney General, or Department of Social Services- Adult Protective Services, or the Office of the Inspector General. Ususally ALF are "surveyed" by the Department of Social Services.

I have seen it packaged separately for each resident, but also I have seen nurses administer meds directly from a large "house stock" bottle (dated when opened). Meds like Tylenol, Calcium, multi vitamins, ect....

Absolutely correct. ALF's are not inspected by the "state" however they answer to DSS (Department of Social Services). Now I know a great bunch of social workers, one which is very special to me, HOWEVER- none of the social workers I know can inspect a bedsore, watch for proper technique on incontinence care or wound care...not sayn they can't- just that they are not trained to do that and according to regulations, only a nurse can look at "private areas". Where I come from, the ALF's are private pay and because their rates are cheaper than LTC, thats where people go. Most advertise that they have "Special dementia care" which is lovely, but when the person becomes total care, then who provides that? I have seen nghtmares come from ALF in terms of residents who were really more care than they could handle and developed horrid bedsores, weight loss, and so forth. I am not saying all ALF's are like that...but some are.

According to my state pharmacy regulations: 18VAC110-20-520. Drugs in long-term care facilities. Prescription drugs, as defined in the Drug Control Act, shall not be floor stocked by a long-term care facility, except those in the stat drug box or emergency drug box or as provided for in 18VAC110-20-560 within this chapter. d. Long term care facilities shall destroy discontinued or unused drugs or return them to the pharmacy within 30 days of the date the drug was discontinued. Please check the specific regulations in your state and your facility policy and procedure.

The problem is- if the treatment is not done or there is a reaction, or something happens- whose initials are on the TAR? Yours. Who is responsible? You. The CNA's need to sign their own sheets- CNA treatments should not be on the nurse's TAR unless the CNA is able to access the TAR and sign the treatments they do themselves.

The facility should have some standard documents they use.