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Medicarenurse1's Latest Activity

  1. Medicarenurse1

    MDS - Where to Begin?

    Talk to your current MDS coordinator(s). There are big changes coming on October 1st, which may make some facilities not want to hire a new person until after the dust settles. Also check out: American Association of Nurse Assessment Coordinators. (Google AANAC). What we do is a 500 question assessment, which sets the payment rate, quality measures and lays out the bare bones for a federally (CMS) compliant comprehensive plan of care. There are specific guidelines for when admission, annual and quarterly assessments are compiled and transmitted, with sometimes only a 3 day window of Assessment Reference Dates. It takes a long time to understand all the niceties of the job, which includes analyzing a whole lot of data, and making sense out of charting that makes no sense. Currently skilled SNF patients can require assessments every 7 days during the skilled stay. Hope this helps.
  2. Medicarenurse1

    Only Crusty Old Bats will remember..

    Evening shift gave backrubs to all with one bottle of lotion, not a glove in sight. Taping hip to a full side rail, with buttocks exposed to the door so that the heat lamp could be on the sacral decub for twenty minutes and leave the door open so I don't forget about the heat lamp. Bedsores before "stages" and debriding without a doctor's order.
  3. Medicarenurse1

    Ridiculous medical mistakes on TV

    I liked House, where the doctors were always giving meds. Yeah, right.
  4. Medicarenurse1

    Questions for an acute care nurse.

    Hi, I'm an MDS coordinator, and as an acute care nurse, you would have no reason to know what that is, but my job is to provide clinical information to CMS for reimbursement. We have several levels of care in nursing facilities, and when a person comes for skilled care, it is my job to reconcile the admission diagnosis with the hospital stay, as we are considered a continuation of the hospital stay. This is true even for residents who live all the time in our building, but have come to the hospital for acute illness and return to us at a "skilled" level for a short period of time. I also have to report to CMS changes in wounds (sometimes every 7 days) so if I have measurements on discharge from the hospital, and no one in our facility measures the wound til the next day, I can tell if there has been a significant change. In my role, in addition to an admission assessment, I am responsible for the total plan of care, and the more information in that packet, the less invasive I have to be to my co-workers fighting for the chart. Also in the event of some skilled admissions, there is a "look-back" period that extends back into the hospital stay for surgery, ventilators, oxygen, IV meds, transfusions, Bi-Paps, you name it, that CMS expects us to address on admission. Functional assessments from PT/OT and ST or swallow studies are pure GOLD. Since we are usually an extension of the hospital stay, it is common sense that we need all the records from the stay. Hospitals are famous for forgetting to mention that the sitter was still in place on discharge (not really "legal" for us to accept) or leaving out the nursing documentation that the patient has a large, involved family who mostly don't speak English (we need more time to arrange translators,) and other social information that is critical to make the patient confident that we know what we are doing. ALSO, the industry standard for answering call lights is very different than the hospital setting, and people are rarely ever prepared for that. Hope this helps a little.
  5. Medicarenurse1

    Restorative right or wrong??

    In a perfect world, the floor CNAs would be able to do restorative programs, most especially ambulation, brace/prosthesis assist, feeding and actually all of them. The CAVEAT is the charting for both the CNAs and the nurses. The RN needs to over see the plan and tweak it, and write a progress note (narrative-not checkbox) weekly or at least monthly. In order to count for reimbursement, that is. Also, just to clarify, it is OK, I repeat-Acceptable and OK to employ restorative techniques that are provided to MAINTAIN THE CURRENT LEVEL OF FUNCTION. This was in the last revision of the Medicare laws. If a person is likely to decline without being cued and prompted to put joints through a full functional range of motion, then ROM is perfectly acceptable, but it should be observed and not just reported by the resident to the CNA. Not opinion, part of the rules. Just ask them to show you or the CNA what they did this morning.
  6. Medicarenurse1

    section L and M question

    If the Braden is 18 or less, I proceed even if I don't think the person is really at risk, and I do that to cover my clinical decision. However, I care plan almost everybody except ambulatory psych residents if they are even rarely incontinent or need assistance just at night with bed mobility. I definitely over care plan skin, but sure as I don't the surveyor will walk in on someone with a stage II from sitting on the toilet.
  7. Medicarenurse1

    No pain meds in ER??

    Went to an ER six months ago with an acute kidney stone, 200 + miles from home, knowing it was probably a kidney stone. Drove to a hospital I was familiar with in the area (I travel the state as a reimbursement nurse for LTC.) Could barely walk when I came in the door, and was given two acetominophen. By the time they got a scan, it had passed into my bladder. I point blank asked the Dr if he thought his treatment of my situation was appropriate, and he said yes. I disagree. 2mg morphine would have reduced the spasms that I had after the fact. On the other hand after I had a car accident, in an ER 300 miles away, but still 200 miles from home, I was offered and almost received 10 mg morphine for the after effects of a roll-over car accident from which I walked away with a tiny scratch on my hand and a mild concussion. 10 mg was totally uncalled for, and 2 mg did the trick. There don't seem to be any standards for opiate use. When they are needed, they are NEEDED. But a 120 lb person who can walk probably doesn't need 10mg. Fractures would have been a different story. And meanwhile in my every day life, my chronic arthritis pain is managed with doses of Advil and ASA that are far more harmful than opiates would be.
  8. Medicarenurse1

    Facility refuses to give raises

    One community where I worked, people in my position would step sideways every two years for this reason. I am an MDS coordinator, so when one facility lost an MDS person, we all moved over one facility. That kept us from getting into a pay rut. Each facility would have to pay about a dollar an hour more than the last place just to fill the position. Worked my way from $64,000 to $78,000 in six years this way, and everyone benefitted. You have to be able to market your skills to do this, though. I worked with some CNAs who stayed in their jobs so long that new hires were making more than twice what the career/lifetime employees were making.
  9. Medicarenurse1

    Guilty and relieved at the same time

    Well, I've been in LTC now for the last 16 years. What I have seen is that facilities ebb and flow in quality. I have worked at 5 Star facilities and 1 Star facilities, helped get a de-certified facility back certified, and lots of other in between situations. I have seen staff that stays through thick and thin, not understanding how they can suffer the low tide times. I tend to ditch fairly quickly (once within 12 weeks) if the care is too scary. I never fear a new job when coming from a bad situation. Later when I check back I usually find that things have improved after a time. Long ago stopped worrying about residents receiving sub standard care, and like any good airline passenger, keep my own oxygen mask on before helping anyone else with theirs. The point of this ramble is that my own philosophy is not to support bad care by staying.
  10. Medicarenurse1

    Med A - Diagnosis

    You do not code the fall again if you coded it on the DC assessment, IF the resident was coded as DC Return Anticipated. If you had to do a re-admission then you code a fall in the last month, and a fall with fracture in the last 6 months.
  11. Medicarenurse1

    pain interview

    Yes, the pain assessment is necessary on all assessments. Non-medication interventions require an order (can be a nursing order or physician order) and require a response as to whether the intervention was effective.
  12. Medicarenurse1

    Mds nursing

    Why do you want to be an MDS nurse? The why is way more important than the "how." If you are tired of passing meds, that's not a good reason. Don't want to work nights and weekends-not a reason. Getting disabled-not a reason. If you want to understand the care planning process from beginning to end-that's a reason. If you want to make sure your facility Quality Measures are monitored correctly-that's a reason. If you want to effect positive change in your facility for better care for everyone-that's a reason.
  13. Medicarenurse1


    I usually do open a sig change on fractures if the resident is not likely to heal within a couple of weeks. you can always delete it if you don't need it, but I open it to clue the team in to observe for a change.
  14. Medicarenurse1

    Nursing Supervisor salary

    True with a caveat. It takes years to learn all 6000 laws regulating nursing homes in the United States, and missing some of them will lose you your license, just sayin....Remember 6000 LAWS governing, and you are responsible if your staff does not obey all, all the time.
  15. Medicarenurse1

    Social Media

    I was visiting a facility where a new CNA came to the DON and resigned on her first day on the job. Someone had posted something mean about her on facebook after she got to work. The astounding thing was that three of the managers in stand-up handed me their phones at the same time so I could read it. (I am "corporate"). so I looked around and said "How many people are on facebook right now, while we are paying you?" The front desk receptionist had her phone in a public facing area, with facebook up. No one had gone on break and the posts were all timed since the employees had clocked in. How do you have time to POST (never mind read) this stuff when you have 10 patients to wake up, toilet, dress, transport to breakfast, feed and clean, re-toilet, you get the picture. The administrator was on paternity leave and no one was running the building. I emailed everyone I could think of and two weeks later there was not a phone in sight when I walked in after the administrator came back. I was astounded. I love checking facebook AT HOME or at night in the hotel room when travelling, but NEVER
  16. Medicarenurse1

    HELP!! Care plans on MWD orders

    The MAR and TAR having these things on them allows you to document that you did assess for behaviors, side effects and that you took preventive measures for risks. They may well be on a care plan, but no one will document that the way they do in the hospital. It is on the MAR to assure compliance.