txdon

Okay, I need more help or suggestions. My facility has serious issues with the number of resident's who receive daily baths. There are two sides to my facility, one side gives atleast 14 baths per shift. A total of 28 baths per day just on one side. I have a bath aide but the problem is when we are without the bath aide residents don't get their bath. The CNA's have grown accustom to not giving baths anymore so when they are responsible for the bath it usually doesn't get done. Instead of have four CNA's on the floor with a bath aide, I am thinking about having five CNA's on the floor and having everyone responsible for their own baths. The concern I have with this is how to manage that baths are getting done. Any suggestions?

Does a resident have the right to demand who his caregiver will be? Is that consider a resident right? I have had two residents who have demanded or refused care by a caregiver because they only want a certain aide or nurse care for them. They don't want to forego care, but demand it on their terms. This is largely in part due to manipulation. I have one aid who takes over an hour everyday to give a bed bath. I need clarity. Thanks

Help! My facility is having its annual survey and we are possibly facing a g tag. I am apprehensive talking about this situation online but really need so guidance from someone who understands actual harm citations.

First, does anyone have a clear job duties list for CNA's on nightshift. This shift is my weak link. Basically they think their job is just to answer call lights and maybe clean a few w/c's. Second, I am having a difficult time getting my nurses to sign the PRN Painflow sheets when they give narcotics. They are very consistent when it comes to signing out the narcotic, however they forget to sign the PRN Painflow sheet to show the resident's response and effectiveness. I have given inservice after inservice but they are still not consistently doing this. Any suggestions on how to fix this problem?

What are T&P clocks and audits? All residents are on air mattresses, these particular wounds were acquired from sitting - both were on strict orders to only be up with meals. The surveyor felt that one resident should have had more interventions in place to prevent a shearing, such as dietary supplements. The other one, the CNA's failed to adhere to the strict turning and positioning orders. We use the Braden Scale.

I just had a complaint survey that resulted in a G tag for wounds - F314. Both cases involved failure to do enough to prevent further progression with a facility acquired wound. Both started as Stage II's and progressed, one resulted in osteomylitis. As a new DON, what does this mean and any suggestions on how to clear this for the revisit?

My facility cencus is 89 with 19 Qmix. Thanks for clarify careplans and quarterlys. At my facility we don't have unit managers to oversee this process. Each nurse is now responsible for careplanning t.o's and changes. They are assigned 8 residents who they are responsible for doing the quarterlys. One more question: The current MDS nurse is always harping on the poor quality of charting. What is truly need for the MDS nurse? We do daily head to toes and a small narrative regarding what transpired for the resident that day. Any suggestions on how to improve documentation?

I think a large part of the medication not being available is due to nurses not reordering the medication in a timely manner. Usually this occurs towards the latter part of the weekend, leaving the weekend staff scrambling. Any suggestions on how to improve this system?

Ok, I will admit I am not at all familar with MDS. I am a fairly new DON and need some MDS advice. The current MDS nurse wants the floor nurses to do careplans when they write new telephone orders that would warrent careplanning a new diagnosis or behavior. She is also wanting the nurses to do all the quarterlies for her. It is my understanding that MDS 3.0 requires the MDS nurse to do the quarterlies. My nurses are already overwhelmed with everything else they are responsible for. Any advice?

Recently our corporate pharmacist did an audit and identified several times nurse's circling their initials on the MAR and writing on the back," Medication unavailble". Can someone tell me what nurse's show write on the MAR when a medication is unavailable? I have instructed my nurses to call the Dr and request to hold medication until it becomes available. Is it okay for the nurses to write on the back of the MAR,"Hold medication per Dr. order." or should they write something else?

Thanks for all the wonderful advice. At my facility the "wound nurse" is responsible for doing weekly documentation on all pressure and non-pressure wounds. She follows the resident weekly until healed. She is responsible for doing a weekly assessment of the area in question but not a head to toe. The head to toe assessment is the responsiblity of the floor nurse who is assigned that resident. The wound nurse has designated one half and one full time day to document and assess wounds. Her full time day consists of pressure wounds, usually about 15 residents. Her half day consists of non-pressure wounds such as skin tears, bruises, etc. Ususally they go much faster because it is basically monitoring or documenting area resolved.

I need help developing an effective wound care program at my LTC facility. I currently have a wound care nurse who does all the wound measurements for pressure and non-pressure wounds weekly. She puts them on a special tracking form that includes that family, dr has been notified, careplan updated, etc. The floor nurses are responsible for the daily wound treatments. Once a week the wound nurse comes to the weekly care conference and reports findings. An IDT note is written on the progress of the wound. The progress note usually consist of current measurements and continuing with current treatment. The nurse I have doing measurements wants to do wounds full-time. She works on the skilled nursing side and thinks she is more than just passing meds. I clearly explained to her that I didn't have a budget of a full time wound nurse. As a result, she is unhappy, complaining she isn't able to effectively do her job. Basically, she feels as though she is being asked to do 2 full time jobs and she says she doesn't feel safe doing the wounds because she isn't able to put the time needed. I will say I have questioned if she is actually even looking at some of the residents on the list, or if she is just putting the same information back on the report on a few of them. Also, I had a resident with a rather extensive wound - it started on her abdomen, and tunneled down to her perineum. This particular wound had three sections. She only documented the abdomen. Also, she is constantly complaining that our wound care program is a mess. She recently mentioned that supplies are left in all the resident rooms, weekly progress notes are not being done, etc. I have to admit wounds are not my strength. My facility currently has 6 resident's with FAPU's. I am needing some help and resources.

DON's I need your help. I need help developing an effective wound care program at my facility. I currently have a wound care nurse who does all the wound measurements for pressure and non-pressure wounds weekly. She puts them on a special tracking form that includes that family, dr has been notified, careplan updated, etc. The floor nurses are responsible for the daily wound treatments. Once a week the wound nurse comes to the weekly care conference and reports findings. An IDT note is written on the progress of the wound. The progress note usually consist of current measurements and continuing with current treatment. The nurse I have doing measurements wants to do wounds full-time. She works on the skilled nursing side and thinks she is more than just passing meds. I clearly explained to her that I didn't have a budget of a full time wound nurse. As a result, she is unhappy, complaining she isn't able to effectively do her job. Basically, she feels as though she is being asked to do 2 full time jobs and she says she doesn't feel safe doing the wounds because she isn't able to put the time needed. I will say I have questioned if she is actually even looking at some of the residents on the list, or if she is just putting the same information back on the report on a few of them. Also, I had a resident with a rather extensive wound - it started on her abdomen, and tunneled down to her perineum. This particular wound had three sections. She only documented the abdomen. Also, she is constantly complaining that our wound care program is a mess. She recently mentioned that supplies are left in all the resident rooms, weekly progress notes are not being done, etc. I have to admit wounds are not my strength. My facility currently has 6 resident's with FAPU's. I am needing some help and resources.

Help, we have a resident who is declining rapidly. She developed a stage II and within a couple of week's time it has progressed to a Stage IV! She was just put on hospice but I am concerned how to clearly document this progression effectively to show all interventions were in place to prevent the progression of the wound. She was on an air mattress, with q 2 turns, etc. My question is: When a person develops pressure ulcers, is the facility always at fault, regardless of the disease process? She refuses to eat or drink, remains in a fetal position, basically her body is shutting down. Her family is very upset with this wound and is blaming the wound for her failing health. Hospice has said this wound is non-healing. Finally, what are surveyors looking for when it comes to wounds that are facility acquired?

My facility policy is to write an IDT note on every person with a non-pressure wound. We are expected to write a note weekly until healed. The problem is I have multiple residents with non-pressure non-healing wounds that remain status quo. I need help writing a good note that will address the fact nothing has changed with this wound, but want to have all basis covered with survey. I thought about addressing the wound monthly unless otherwise indicated. Any thoughts? My second question involves a resident with Tardive Dyskinesia. He has significant EPS and I need suggestions on how to write a good note addressing this. The EPS is non-reversible and I know several facilities have been tagged for not addressing it. Any suggestions?

Thanks for the responses. One problem I have is with new admissions who are on psychotropics. We have to fill out behavior sheets upon admission, but often times behaviors are unknown as to why they are taking the medication. Largely in part because the medication is controlling the behavior, so behaviors we put on the behavior sheets are solely based on the type of medication they are on. Recently my administrator said "Hollering at the staff" is not considered an appropriate behavior. This particular resident screams instead of using the call light and hollers at staff. What should be put on the behavior sheet? Finally, we recently had a dr. who wrote a t.o for a pain medication to be given q 4 hours "while awake". Since we are in the middle of end of month change over, I need to find out just how this should read on the MAR. The medical records manager who puts in the MARS says it should be at 8am, 12p, 4pm, and 8p. My unit manager and I believe it should show 6 times over a 24 hour period 8a,12p,4p,8p,12a,and 4a. If the resident is asleep during any of these times then the nurse needs to initial and circle the medication was held due to resident asleep. This way we are not automatically assuming resident is awake during the day hours only. Any thoughts on how this should be put on the MAR?

Thanks debRN for your comments. At my facility our policy is whenever the resident falls and it is unwitnessed, we have to do neuros. How should I go about changing that if that if that is the policy? Also, we have had a high number of falls last month. As a result I have been asked to write an action plan. I have never had to do this before. The falls have decreased signficiantly this month but they still want an action plan. Any suggestions on what the action plan should consist of?

Why would your facility want you to do away with bed/chair alarms? We use them not as a form of restraint, rather as a reminder to seek assistance before getting out of bed for those who are impulsive and forget to call for assistance. Alarms don't prevent residents from getting out of their bed or chair. It is used to "alert" staff to help them to this in a safe manner.

I have a resident who "slides" out of bed onto the floor when trying to ambulate to wc. She is a one person assist and has a transfer pole to promote more independence to and from bed. When she slides out of bed onto the floor she is unable to get up. She uses her call light for assistance. When we ask her what she is doing sitting on the floor is will say,"I didn't fall. I am sitting on the floor looking for somethig, playing cards, etc." She knows we have to treat it as a fall and start neuros, etc. The problem my staff is facing is how to continue to careplan this appropriately. We have ran out of interventions to use to prevent this from continuing to happen. I know when the surveyors look at this pattern they will question our lack of effective interventions. One reason for perhaps her slips out of bed is the fact she insists on wearing silky nightgowns. That is her perference. Can anyone think of additional interventions my facility could implement or any new fall prevention measures to prevent the resident from getting up and ambulating without assistance? And how should this be careplanned?

Does anyone have a list of appropriate behaviors to use when doing behavioral sheets for psychtropic meds? The nurses are having a difficult time with this.

I need help with my nursing budget. I need to make drastic reductions and would like some ideas on how to reduce spending costs on nursing supplies.

Can someone please help me understand why unplanned hospitals discharges are such a negative in LTC and SNF's? I recently had 6 patient go to the hospital, five out of the six were admitted. Only one out of the five I feel we could have treated within our facility, but the Dr. insisted we send her out. I have received a lot of grief from corporate about "why" we are sending out so many people. How do other DON's judge on who should go to the hospital?

In my humble opinion I believe that nurses behave this way because they've been allowed to get away with it - holding staff accountable is vital. Unfortunately most DNS are "afraid" because they can't afford to lose them. I am facing this very issue. The previous DNS was more worried about everyone liking her than what was best for the residents. As a result, an environment of tolerance and denial evolved. My dilemna is I am now left to "fix" these problems. The only person on the nursing management team is a loyalist to the former DNS. She is very much like the former DNS and want to be buds with CNA's who should have been fired months ago. She goes outside and takes multiple smoke breaks with them, "ignores" them goofing off, taking multiple breaks, and not giving good resident care. Also, the former DNS has allowed her to wear breast piercing that are visible, facial lip piercings and ear gages. This is what I am faced with. When new employees start I emphasis that facial and body piercings are not allowed, however their response is well the manager wears them. I know what I need to do, any suggestions on how I should approach this?

Just you caring enough to ask this question says a lot! I agree with the prior two post, it is vital that the administrator allow the DNS to handle the clinicial issues. In my situation, I have a DNS with over 25 yrs experience and plays a large part in helping. The best advice I could give is make sure your DNS is able to lead her department. One thing I love most about my administrator is that she does not allow other department employees go around their manager. There have been times when employees thought they could go straight to her and complain about something they didn't like. Her response is always, "Have you spoken with your DNS?" Can't tell you how much that means to me. Best wishes!

If the "primary" nurse is not on duty, the responsibility would fall on the nurse who is on duty. The "management" part would be that of the "primary" nurse. I am in desperate need trying to figure out an effective nursing staff model. Our facility holds up to 90 residents, but usually has between 80-85. We have 3 LTC units and I skilled. Skilled hold up to 20. Currently we have one unit manager for one side, which consists of 1 LTC hall and skilled. I am desperate to hear from other DON's who have ideas as to what has been most effective.