TigerxLiLy

I don't even bother bringing in my stethoscope to the covid rooms—- usually the cheap one inside does well enough to hear the junk in most of the lungs— plus- most of the med surg covid rooms have those “air filter fans”.

Yep— mine would get twisted in the mask, slinged shot across the room or so much pressure from the mask/shields would cause pressure injury behind my ears.

I use “in the ear canal” hearing aides now— did have the behind the ear- but with the masks they kept flying across the room even when I was trying to be careful ?? (they were 7 years old so I was OK with getting a upgrade) I am using the Eko— it CAN bluetooth to my hearing aides- but the sounds is not the same- heart sounds are literally missing the S1/lung sounds are weak. However— I just put my bone conductor headphones (just got them didn’t think about using them with stethoscope!) I can keep my hearing aides in and auscultate the S1 s2 very clearly! My patients already think im listening to music with my black in-ear hearing aides, why not add my headphones! with n95 mask on— the bone conductor headphones will just be another thing on my head ?? so probably just easier to take out one hearing like usual tho.

Sigh. Completely makes sense - especially with the certification listing the diagnosis/md signing it :). thank you

Kinda sounds like redundancy/annoying the providers with stuff that’s obvious...

Read on a AANAC article that if the D/C summary states that the dx is resolved, we cannot use the diagnosis, even if the main reason needing therapy services - that a MD Query must be completed to support that dx is in fact “active”... — article quoted here:https://www.aanac.org/Today-in-Long-Term-Care/post/mds-item-i8000-solve-common-coding-problems-under-pdpm/2020-04-01 “Resolved diagnoses. The coding instructions on page I-7 in chapter 3 of the RAI User’s Manual state, “Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the seven-day look-back period, as these would be considered inactive diagnoses.” Coding resolved diagnoses is an issue at some facilities, says Maher. “For example, the hospital discharge summary may include a resolved diagnosis of pneumonia, but the IDT believes it’s still an active diagnosis because the SNF is providing antibiotics or doing lung assessments and therapy related to the pneumonia, so the NAC codes it in section I.” If the hospital discharge summary states that a diagnosis is resolved, the IDT can’t decide that it is still affecting the resident and needs treatment—and can be coded on the MDS, says Maher. “When the IDT believes that a diagnosis is active even though a physician says it is resolved, the appropriate step is to query the resident’s attending physician, I.e., ask whether the attending physician would document that the diagnosis is still an active diagnosis related to the continuing need for treatment for that diagnosis. Taking this step is important for payment in PDPM—and also to ensure that the diagnoses accurately reflect the resident’s diseases and conditions.” I used to have MD query forms at my old facility (we placed them in the Physical chart to have back up documentation) but my new one does not (they have us calling the Dr, asking about the dx, and asking if they can addendum the progress note they did in the ARD window- which it sometimes doesn’t happen/no back up documentation) ... anyone happen to have a MD Query form?

Thank you Talino. I swear i have read the medicare guidelines - guess i just remember reading it- and sorta related it to my corporate office (maybe thought it was their rules.. Who knows) Just ran into this issue when we admitted a new patient from a sister facility of ours... I told our administrator that the patient didnt have a wellness period based off our calculations. Was skilled at other facility for a hip fx from 4/29 to 8/7- used all 100days. Then on 8/28 it is noted in hospital records that she obtained a PEG due to not eating orally- breaking the wellness period. She admitted to psych unit on 10/27 - h/p notes she was recieving TF and pleasure trays at other SNF. She recieved 80cc/hr x12hr feedings at hospital. Administrator, DON and Myself felt assured that resident did not meet her requirements for skilled care. Yet, the other SNF was skilling her for 5 days prior to admitting to us...

I have been told that a PEG that is giving a patient 26% or more of daily nutrition is considered a skilled service in a LTC setting. Was told that when the patient uses their 100 days that they would never accrue the 60day wellness period as long as the above was still effective in a LTC setting. Is this accurate? It seems the medicare guidelines are vague in the aspect of what is considered "skilled" sometimes...

*Venting* We have RUGS meetings every Mon/Wed/Fri per corporate. SS,DOR,restorative, myself the PPS coordinator, Medicare part A nurse (who is suppose to document on and follow their medical progress and do dc planning with family) and either the DON or administrator. Today neither the DON or Administrator were present. We had 15 part A and 4 managed care people to talk about in a hour today...which is usually done pretty well.. But today, I was particularly more agitated over the med A nurse texting on her phone and not really adding anything to the conversations ...just "nope everything's fine" when I ask how specific things were with each patient. (She always is texting in RUGS (when the big bosses are not there) rarely gives input on residents...I am always having to tell her what is going on with the patients- instead of vice versa) She had 2 care plan meetings with families that morning and hadn't seen all the patients ...which is understandable. But after 15min of typing on her phone off and on and looking bored.. I ask Her "are you texting the Dr or can we put the conversation on hold?"...she didn't answer.. So I asked again.. She looks up annoyed and states "yes I'm talking to the Dr,I'm trying to get my work done."I just say "ok".. And continue... But then she pulls out a piece of paper,writes on it and passes it to the restorative nurse...who then laughs and writes something back. I then unfortunately, regretfully, lost my control... Stood up...looked at the Med A nurse... Stated "you are wasting our time here,that pisses me off so much I could punch you. I'm done here today. Meeting is over." As I walked out,I cringed...went straight to the administrator..told her what happened.. Apologized for my unprofessional behavior but told her I was tired of doing my job and hers as well (I need the med A nurse (who if we didn't have would be the equlivant of the supervisor) to inform the team of medical issues/changes that have arrived so we can discuss if the appropriate interventions are in place and what is needed in documentation... But I'm cconstantly being told "everything is fine" yet when I go behind to make sure everything is NOT fine..) Friday on RUGs -the team decided MS.x was not making progrss in therapy,I asked the med A nurse if there was anything medically that could be hindering therapy...I stated "vitals? S/s uti? Blood sugar issues?"...med A nurse goes "nope. She is stable"..so we put in the 48hr notice. This morning... Her CBG was 24... Look at the past weeks CBGs in AM...all 50 with nursing giving juice w/sugar to bring it up...which the med a nurse sees every time she documents in the electronic chart./facepalm So of course we can't let that patient go home...but we almost did because the med A nurse wasn't paying attention. I snapped today.... I did...I don't know if I want to go back...or if I should...

Since this discussion is open... Rehab Low requirements Do your faculties mandate that the therapy department transition to RNP with each discipline doing 3 days QOD of 15min(training restorative)? To get a rehab low... It just says 3 days of any combination of therapy...so if I had OT/PT/ST in and we are transitioning out to restorative.. Could technically it just be like this: Day 1: PT and Restortative nurse develop resident goals and PT trains nurse with resident on techniques and special precautions. (Restortative aides could be present.. But for this example we are going to pretend the nurse then trains the aides separately) D2: OT and Rest. Nurse do the same as above D3: ST and rest. Nurse do the same as above D4 to 6: rest. Nurse trains aides with resident. Does it really take 3 days of training? If we only had PT/OT in...could PT. Start with 2 programs( arom and walking) day 1. Day 2 OT do a reg treatment...then day 3 or 4 OT do their RNP training ...to still get the 3 days? Just a thought Do your restorative programs go beyond ADL activities? (Like "door pulley for arom" or "nustep bike for 20 min" "or something else therapy did in their activities that I can't rremember off the top of my head)

Only RNs care for your Med A's?how does that work? The have their own ward? What's your med A patient:nurse ratio? How do you deal with LTC patients that come back skilled on a different hall?.. Trying to convince my boss to do a ward with just RNs... But with 5 RNs on night shift that end up missing tons of issues and missing documentation on weekends.. Doubt it'd work.

...did.. Answer was "I have issues at home and I have not been all there in my head"... I directed her to our DON with that statement.. If you can't focus on the patients because of "home life" then you should not be working.

Care Area Assessment.. It's on the comprehensive MDS (Admission,Annual,Sig change assessments).

Hi, * I am looking for ideas to better organize our IDT team.* I know each building has their own ways of communicating and "getting things done", but I am researching and would like to know a little about how your IDT functions. My facility currently practices the "Silo" team= each department does a generic assessment,then the MDS coordinators gather the info, throws it the assessment and the coordinator develops the CAAs solely on that information and the coordinators own assessment. No input from other departments.. The care plan meetings do not feel "coordinated".. They are usually just "sit down with family,discuss what's happening in therapy and current Dx and treatments,and what the dc plan is" not much talking about interventions that resident/family initiates. * Just a few questions: * 1. Do you guys involve the SS, ACT, Dietary into completing some of the CAA's? Or do you guys develop the CAA's based off their assessments alone? * 2. During your IDT care plan meetings, Do you bring the list of CAA's to the careplan meetings to discuss interventions? * 3. Are there instances where you complete a care plan meeting with the family before the CAA's are developed? * 4. What CAA resources do you use? The RAI CAA tool sheet? or just based off nursing knowledge and experience? * 5. How do you guys incorporate indvidualized interventions into your careplans? Sometimes I feel most of our interventions are protocol/policy based or generic. * Im not sure if these questions will make complete sense, But I am looking forward to hearing what other MDS/PPS coordinators are doing to better develop their team and Careplans.

I guess the nutritional focus will have a direct relation to DM, GERD, CDiff, anything GI related.