pixie120

I understand the floor nurses are busy, when they get a new dx/treatment, all they have to do is turn to the careplan, handwrite somewhere a new C/P: UTI goal: Resolve UTI Interventions: ABO as ordered, montior for ASE of ABO, report s/sx new UTI once ABO done. Takes a minute. Good practice, good for all. Surveyors just exited our building, spent far more time with floor nurses than ANY of the nurse manager staff. IF your floor nurses were to say "Oh, I dont' do that, the MDS , RCM, SDC, DON does that.........." Really, and are they the primary care nurse? It doesn't fly. The more times they practice a short term c/p the faster they will get at it. Same with elopement, new fall, new injury, interventions are just whatever you are doing right then for the patient. THe nurse managment team can come behind later and tweak the careplan. I have been for over 10 years as a nurse manager, careplanning events I never witnessed, wasn't in the building when it happened, and now have to investigate, re-interview etc and then careplan the event. It can be careplanned, investigated immediately, takes a few moments, the more you do, the more you know and the more it makes sense to you. (That's how I learned....).The witness statements need to be filled out right away, by the C.N.A, then the nurse careplans it, so...if the nurse adds a wanderguard, go careplan it short and sweet. The number of resident's that the nurses are now expected to care for has dramatically dropped, taking care of 15-18 residents, in LTC is very doable. Medicare 10-15 very doable. No time to sit around and cry,whine and point fingers...and if you do, PLEASE careplan that!! And in this state, the economy is affecting nurses as well, and we are finally seeing nurses understand that and be willing to step up to the plate and be part of the nursing team. Communication is everything. If the floor nurses can't do short term careplans, or if they say they don't know how or don't have time, get them some training and support them in this learning process. If they have their heads buried in that bloody MAR, for god's sake stage an intervention. MOst of those meds are completely benign, useless and if the floor nurses would speak to the families and MD, can whittle those meds off that bloody MAR, and then focus on the actual patient. Careplanning and updating the CNA careplan/Kardex if far more important than making sure 89 year old Wilma gets all 16 of her bloody vitamins, plus one important med. WHen I was running a 40 bed dementia unit, we whittled those drugs down to the barest nubs of important cardiac, HTN meds (and some of those can go away as well, ask the pharmacist if you aren't convinced) and no less than 10 had NO meds, ZERO, (and they had a ton less behaviors as well) we made a boatload of Hospice referrals and we focused on pain meds and bowel meds, and then...activities. We took a 4 hour 8 am med pass and got it to less than 1-2 hours, so the floor nurse could supervise the cares given. We also did a ton of care conferences and met with families to increase/personalize the care given, care goals. Yes, it takes time, but it is so worth it!!

Thanks for the information. We review all MDS data, as an IDT, every morning and do the quaterly/comprehensive assessments (Braden, AIM etc) and write an IDT note per each MDS due. We double checked, we are able to combine MDS nurse note with IDT note (it's in Section 2 of new updated MDS manual). It would be nice if the other disciplines did their own data entering but I have to say I much prefer this way as even now, the two other non-nurse staff have to be reminded/prodded to get their sections done and it really holds up the MDS train. I worked in several buildings such as yours, where there were just as many non-nurses "responsible" for entering their MDS information (including the Restorative nurse/RCM's for the RNA portion, Kitchen manager for the weight section) and MDS's nurses were ALWAYS in a dither to get those folks to do their portion. Given that NOW we are in the new, "real time" MDS and "real time" opening the ARD date, and given particularly for the COT's etc, I am very glad it is mostly RN's. I like our new system as well, very IDT. Also, just as an FYI, it's not the MDS that has to be IDT, it's the assessment, careplanning and review of patient care that has to be IDT, which of course included the MDS, we just reviewed the wording, it's all nursing process, the 5, with the IDT meeting weekly or even daily to assess, plan, implement, review and re-assess). MDS is one part of that IDT process. Many things that SNF's have implemented in the last few years with regard to focus on IDT compliment the new MDS as well. Just my two cents...

FYI, in this building we have 3 RN MDS/RCM's, is probably why they do the "extra" work that some don't? Max patients per MDS/RCM is 20, Medicare mixed thru out all caseloads

Thanks for the information. Perhaps I asked the question wrong. In our building the SW does D,E, Q Activities does F and RN/MDS does the rest....so (including CAA's) so my question is this: RN signs for and puts these alphabet letters: A,b,c,g,h,i,j,k,l,m,o,p,V and Z Correct? (RN's imput all data from Dietician, Therapies, only other disciplines who data enter, in this company, are the SW and Activities, RN's do the cognition section).

Ok,good to know. Next question, the PPS folks that were "grandfathered in", they do NOT have to be looked at continously every seven days? (The folks that admitted and had their 5 day, 14 day Assessments,or even their 30 day or 60 day.. rehab is saying, based on their company training, we do NOT have to evaluate them, just those that admit after 10/1/2011).

Umm...exactly. and when other's won't participate, give that information, it becomes quite a quandry doesn't it? Another great thing we just had implemented, MDS nurses now have direct access to the therapy documentations and minutes, how wonderful!!!! We are though, struggling with this COT issue... oh, well, we will figure it out soon!

Appreciate your post, somehow I didn't see it until today.You are so very right, I can't hide what I know....sad isn't it? I am interviewing for several jobs in the area in companies that seem to have a much better handle on this. I will make sure going forward, the support system is in place to make the job easier. THAT has been my lesson this year, lol!

Would you mind if I asked what your PPD is? Must be about 3 or a little under/over? (For Skilled).

Yes, in a wierd way, it does seem much more detached, and as they don't do a verbal exit everyday, sometimes you can actually take a breath here and there. Days 1-3 are not too bad, it's when they go into stage 2 that gets a little rocky. If you want to know WHO will be looked at, pull your QA/QI report, and pick your top 10 (and include skin in that top ten, plus any Hospice, endof life folks). THEN, pull out your blank incident reports, your state hotline number and get ready for the "allegations"that never fail to come out during QIS. This is my 2nd QIS survey, and my 3rd survey in less than 10 months, maybe I'll be a pro at the end of this one? My only complaint is when they are parked in the nursing station, phone/fax ringing, trying to do patient care etc and all 4 want something, from....me. HaHa! It does make the days fly!! Best of luck to you! We are in day 3 today. ( I might regret saying this, but I am starting to like QIS a lot more than the old way, those bluepapers, jammed pack full of the hand written documentation,and then daily exit were a bit much, so....subjective).

SO it would go like this: day one, then 5 day, 14 day, 21 day possible COT, day 28 (30 day would fit here), day 35 possible COT, day 42 possible COT.....thru day 100. I though I read that a COT has to be reviewed for and done 7 days AFTER that last ARD date of an MDS,...if thereis no COT at 35, then why would we look at a COT for day 42? (I do understand the idea that we are to look at their "rug" level every 7 days...but it is associated with an assessment date/period/ARD? So.. if no COT (cuz therapy still RU on day 35, we still look on day 42?). Kinda makes the grace days obsolete then?

Best words of advice I ever got were 1. Never let them see you sweat 2. Tell the truth 3 Continue the best practice care that you always give, as if it were just another day!

Kudos for saying that last line, the other disciplines are kinda irritated with nursing, in our building, sort of an us vs them, "just because nursing has to do another assessment....". I think they just don't get that they are also going to have to do assessments in their sections, we don't know yet all that is going to occur, and I get the feeling that some are trying to hide heads in sand, cuz it's gonna be a bumpy ride. We have dedicated MDS nurses 2 for about 75, Medicare about 15-20 average and a couple of HMO's. MDS nurses do the careplans, other's do the quarterly assessments. They are already irritated that we moved up many MDS's to get done by 9/30/11, so we could concentrate for the change. Thank-fully the rehab manager has had extensive training, albiet kinda late in the game, but training none the less, I think therapy is going to be the busiest, and their goals are now changed to attempt to keep rates at the same for the 5d 14 d and 30 day which typically is the same, at least for the "real" rehab clients.

Ok, here is my question. please check my math here" In looking at all of this, for PPS/Med A, potentially there are ONLY 4 COT's that could possibly trigger? In a perfect world: 5 day: if a COT triggered, would be a combo for 14 day, right? (No matter what day chosen, if even day 8, cot would be due day 15, but the 14 day would also come into paly 14 day: could have one COT on or about day 21 30 day: if a COT triggered, on or about day 37 60 day: if a COT triggered, on or aboutday 67 90 day: if a COT triggered, on or about day 97, but there would also be an opportunity for a quarterly in here, as well. ....and then,.... if 6 people get off at the last station,....what is the name of the conductor> lol!! (My administrator says that what a PPS meeting sounds like to her, if this was 6 then this would be 8 and then if this is 9, that is an RUX, lol!!). And of course, we will review daily for any possible COT's, correct?

Lots of updates on the CMS sites, and this is a great resource. Good luck (I think your MDS 2.0 experience serves you well, but you gotta frame it up better that you have been studying, on your own, well aware of the LATEST changes 10/1/2011 with the COT's etc, and sell it to them. I think everyone is a little freaked out this particular MDS week, lol!

WHen I worked Assisted Living, the pharmacy did our MAR's, and they were always written as per community prescription, ie Tylenol 2 325 mg tabs twice daily as needed. LTC: pharmacy will begin doing our MAR's when we switch over to E-Mar this month, HOWEVER the kicker is, only for the meds they supply...so we still have to input the OTC's. We anticipate lots of tinkering is going to be needed. Are the pharmacies giving any guidance on this issue? FOr years, it has been written as the total dose to give, then it's up to the nurse to supply that dose, in as many tabs is needed, however I haven't liked that system since I saw how more accurate the Assisted Living MAR's are. I would think that best practice is WHAT you are actually going to give, BUT a surveyor during med pass audit will say if you give that long acting Tylenol 650 mg it is NOT the same as Tylenol 2 tabs of 325.... Suggestions?