Zee_RN

Hospice staff -- what are your protocols for death visits when a patient dies? Obviously, if it is a home patient an RN needs to visit and pronounce. But what if it's 2AM and they are in a skilled facility and the facility staff pronounces? Do you visit regardless? No family present, pt is whisked off to funeral home.... Do you have a policy on making death visits based on circumstances? Thanks!

The Plan of Care does not meet compliance standards in the Commonwealth of Pennsylvania either as it cannot be customized (at least for hospice). You can tell hospice is a force-fit into this home care documentation system

When you are evaluating and assessing patients and assigning performance scores do you use the Karnofsky (KPS) and Palliative Performance Score (PPS) or just one of the two or something different altogether? (Such as the ECOG). We use both KPS and PPS but I think that's overkill (hah, no hospice pun intended) as the PPS is based on the Karnofsky. Of course the FAST is used for Alzheimer's patients as well. Thanks!

My organization is fortunate enough to staff in such a manner that our RN Case Managers rarely take call. They work a regular Mon-Fri 8-5p week (salaried position). They take "on call" only when our regularly scheduled on-call nurses are off; for instance, if one of our regular on-call nurses gets sick, takes vacation day, etc. We have a "back-up on-call" list in the event the regular nurse calls off. Also, someone has to staff the daylight hours on a holiday. We take volunteers first. So we have a nurse who works 5p-8a Mon - Fri and a w/e nurse who works Fri 5P to Mon 8A (so there's double-coverage on Friday nights). That REALLY cuts down on the amount of on-call our regular case managers have to do. Not bad staffing for a small hospice operation! Given the choice, I'd go with the MON-FRI routine. Our W/E nurse is awesome-saucebut she does *everything* on the weekends...all evals, consents, admits that may occur as well answer all the phone calls, pronounce patients, do visits, handle emergencies. We have on-call psychosocial too but usually it's the nurse handling everything. :)

We cover incontinent supplies including briefs, chux, creams, wipes ... but we do not provide pull-ups as Medicare has classified them now as "underwear." Some hospices do, though. We have opted not to.

Our aides are scheduled 7 days a week...although few patients are actually seen every day. Some are, though. We like to start patients off with daily visits to get a full understanding of what they need; then we adjust their care plan based on the updated assessment. Actively dying patients are seen 7 days a week by the RN and the aide. GIP patients are seen 7 days a week by RN and aide (unless in hospital; aides don't see patients in the hospital).

I would have ensured the patient was comfortable prior to removing the bipap. Bipap is not an absolute contraindication to hospice...but in a hospital setting, I can see where it would be viewed as incompatible with goals of care. I have had patients on bipap on an inpatient hospice unit with the understanding that once we could wean them off comfortably, it would not be re-applied once discontinued. I had an ALS hospice patient on a "sip-and-puff" ventilator once. So there aren't necessarily absolutes in the hospice world; it just needs to be very patient-specific with clear goals.

What are your procedures for patients who fall frequently? (Or any patient falls, for that matter). We spend A LOT of administrative time dealing with those frequent fall patients, particularly those in nursing homes. We complete an electronic occurrence report from which we then generate a paper occurrence report for signatures. The RN must gather the obvious data--date and time of fall and what exactly happened. He/she must also document what interventions were taken to decrease the risk of falling again. A Fall Assessment is done in the electronic record. He/she must also document the full name of the individual reporting the fall, the full name and title of the person they discussed the interventions with, the full name of the family/POA they notified and certainly the date and time the physician was notified as well. Any data incomplete results in the occurrence report being returned for completion. Sometimes we learn of the fall days to weeks after it occurred if the facility did not notify us in a timely manner. Regardless, all the data must be obtained. Obtaining full name and titles of individuals in the facilities is a huge difficulty here; tracking down workers in the nursing home or personal care home can be quite time-consuming. Also, when you have a patient who falls frequently and you've put in a low bed, perimeter (or 'scoop' mattress), fall mats, bed alarm, recommended q1h rounding (um, yeah), gotten a PT eval .... what ELSE do you do? Our organization insists on finding more interventions and yet it seems we've exhausted our possibilities. What does your organization do in these cases? Thanks!

I work for a small, for-profit hospice. Average census around 63. We have dedicated on-call nurses who cover the evening/nights (5pm-8am weekdays) and the weekend (Fri 5p to Mon 8a). The only times our regular RN CM take on-call is if the on-call nurse calls off, takes a vacation or a day off. It is definitely one of the great things with my company; a lot of small hospices like ours rotate their fulltime staff to cover on-call. Look for a place like ours!

Thank you! That has been our organization's approach as well. I've seen it done differently in another agency. The new reimbursement plan, as well, will be based on the frequency model as you described...higher reimbursement initially, then decreased, then higher again when imminent death approaches.

When you order visit frequency for the RN upon admission, do you count the admission assessment visit as a visit? In other words, if you admit a patient and order RN visits 2 times a week, do you schedule one more visit or two more visits for that week? We currently do not count the admission assessment as a visit as that is when the Plan of Care is developed and is not counted in the visit frequency. Is this common practice? Thank you!

My organization uses an electronic health record system with a very confusing Plan of Care option, more suited for home care than hospice. My question is .... who updates your NURSING plan of care? I'm seeing nursing problems identified by an MSW on a few care plans and this makes me nervous. Of course the MSW/LSW can and does update the Social Work portion of the plan of care. But an MSW identifying "Need for Decubitus Wound Care" or "Altered Genintourinary" seems wrong to me. Thoughts, please? And any links to documentation that specifies who can/can't would be appreciated! (I'm heading to the Conditions of Participation now but not sure how specific they will be in this regard.)

I'm registered for the exam on June 8. The only thing I'm worried about is opioid-equivalent equations and such. I've never done that stuff. How much should I worry? And what is the BEST resource for studying? I have the Core Curriculum and I read it through but wasn't terribly impressed with it (typos and other errors, like duplicating a chapter). I took and passed the online $35 practice exam. Hints, help?

Yeah we have that script too. I WILL always ask the patient the first part "Is there anything else I can do for you right now?" with a easy and relaxed attitude. I will NOT outright lie to the patient and say "I have the time..." I anticipate caring for 14 patients tonight on a med/surg/tele/ped unit with the assistance of an LPN. I will NOT have the time for much!

Mover: because you have to transfer the patient in the semiprivate room, and all his furniture and medical equipment, to another room because the lab test just came back +MRSA. Or because he wants a better view. Or because he's transferred to a lower level of care. Many moves... PR Specialist: I don't think I need to explain this one. Liar: "Is there anything more I can do for you? (here it comes....) I have the time!"

I'll have to call the BON. They've just never been helpful in the very few calls I've made in the past -- downright rude, actually, so I was hoping to avoid that. Thanks for the replies!

In emergency situations, blood can be given without a consent. In nonemergent but middle of the night situations, I've worked in places were (a) the resident -- in a teaching hospital -- was called to obtain consent or (b) the house doctor got consent or © the ER doc got consent (they REALLY hate that). Nurses did NOT get consent, period.

Thank you for that link and the document. Unfortunately, I need documentation specifically about blood transfusions; that is speaking of surgical informed consent. There is mention of a complication the plaintiff claimed came from the administration of blood but the consent for the blood was not an issue itself. So if anyone knows where I can support the claim that registered nurses cannot obtain informed consent for the blood transfusion, I would be grateful. Physicians are maintaining that nurses can get the consent because they are the ones administering the blood -- as opposed to surgery where it is the physician performing the surgery. This runs counter to what I've always held as true and have seen at other facilities. But I can't find the documentation that supports it. Thank you.

In the Commonwealth of Pennsylvania, I have always been told that registered nurses are not to obtain informed consent for blood transfusions; it is out of their scope of practice. Only physicians can obtain blood consents. Does anyone know where I can find documentation of this fact? The internet is NOT being my friend today. :) Thank you!

Yes, I'll take those families over the ones that won't move an inch despite seeing you struggle to get to the patient with your hands full of meds, IVs, etc. I'll never forget having a patient in ICU who was vomiting and six family members were hanging over the bed and would NOT move....yet insisting I DO something! (Yes we had visiting hours and other restrictions but you know there's no bite behind that bark.)

I'm trying to gather information on telemetry unit staffing ratios, including ancillary help. It would be of tremendous help to me (as a manager trying to get a better ratio) if you could answer the following: Type of Hospital: (community or tertiary) Type of Unit: (e.g., surgical telemetry, cardiac telemetry, medical tele, post-cath, etc.) Number of beds: Number of patients each RN has: Do you have a nurse's aides and/or at what census level do you downstaff an aide: Do you have a unit secretary and/or at what census level do you downstaff the sec'y: Any information like this is helpful....I'll answer mine: Type of hospital: Community Type of Unit: surgical telemetry Number of beds: we flex from 16 to 32 (16 always open; flex up during high census) Number of patients per RN: 5 or 6 Nurse Aide: All shifts when census at 100%; downstaff @ 70% capacity Secretary: 4 hours per day when census is >18 patients (which means ONLY when I have both sides of my unit open--we usually only have 16 beds open--so basically, no unit secretary). Thanks!

A&W -- Alert & Weird (Assuming A&W brand root beer is not a local thing?)

Good to know. I was wondering the same thing when my staff asked me to start two difficult patients yesterday (one I got; one I didn't). I got the dark skinned individual but the other obese patient who had very very thick skin (his family even commented on his "alligator hide") I missed. He didn't even bleed when I stuck him, his skin was so thick.

I just wanted to thank you for affirming the weight gain after surgery. I wasn't even admitted -- had an oopherectomy as same-day outpatient surgery and I gained 10pounds when I weighed myself 2 days after surgery. 10 pounds! I have a small frame it was SOO noticeable! I was more ticked with the weight gain than the surgical pain, lol. It took about 10 days for that to drain off.

As others said, because there aren't enough instructors to safely educate large groups of students. I'd love to teach. I'm told I'm an excellent teacher and I can point to a number of very good nurses I've precepted. But I can't afford a master's degree. I have three daughters in college and I cannot afford $25,000 on myself.