dian57

Our facility is trying to develop a system for adequate MDS documentation. We have tried posting diagnosis driven cheat sheets (document on at least 2 of these items/shift) posted on the chart and a check-off flowsheet with lines on the back for narrative notes. We have revised our CNA documentation flowsheets to reflect MDS language. Our 2 year trial of EMR CareTracker was a disaster and we have returned to paper. It seems no matter how much inservicing, reminding, checking, reinforcing we do, our documentation is not there or inaccurate many times. Each time I do an MDS I get one set of information from the CNA sheets, another from the nurses notes and yet a different picture from staff/family interviews. Has anyone successfully managed a way to obtain consistant and accurate documentation in the record?

Risk for falls with injury will be reduced. Then list all the interventions you have in place to reduce the risk.

A 20-something woman and her mother came in looking very, very concerned. Problem? Daughter swallowed her gum. Therapeutic wait? You betcha.

First, I am NOT saying the facility was not at fault in this case. But a word of caution must be spoken. We (the public, not just nurses) really need to keep in mind that this story was printed in the media. The media, in my experience, is not always extremely concerned with getting their facts 100% before printing. The reporter most likely interviewed the family, who are understandably upset and angry over the incident. The facility cannot, without violating HIPPA laws, comment on their investigation of the facts. Anyone who has ever read a story like this should keep in mind that we are hearing ONE side, reported by the media. During the trial, the facts will emerge and the story may end up being a little different. We may never see THAT article, however. If the staff and facility did, indeed, attempt to cover up this incident they should be punished appropriately. But before final judgement can be passed, there has to be more investigation and all the facts need to be considered.

Since we initiated the supervised activity program the only falls we've had are rolls out of bed (onto bedside mattresses) and late night wandering out into the bathroom (although staff was alerted by bed alarm, couldn't get there in time to prevent fall). However, NO injuries, which is great. After 3 pm we really don't have other departments available for inclusion in the program. SW goes home early, dietary is busy cleaning up, rehab is still doing programs/therapy of their own. After 5, when LTA goes home, it's all nursing. I'd like to include them in the daytime supervised activities eventually. Years ago we had an All Hands On Deck kinda program--everyone (including Administration) came out of their offices and departments, handed out the meal trays and stayed to help feed. We were MUCH smaller then and unfortunately this has since gone the way of the dinosaurs. Sometimes the nurses take a wanderer with them on the med pass or rounds to keep them busy and supervised.

We have the same issue (doesn't everyone in LTC?). We instituted 1/2 hour activity "bursts," as we've determined our population doesn't have much more than 30 minutes worth of attention span to devote to any given thing. We started with the evening shift as the fall numbers were greater, we've since expanded to the dayshift, too. I've changed the program names to minimize identification of our facility. But feel free to use any ideas that might work for you. No matter how short, however, we always have a staff member with the group--in 1/2 hour assignments. 3-3:30 pm--TOASTing. Give everyone a 120 cc cup of juice/water. The person running the program makes up toasts. "Here's to the President of the United States!" and everyone takes a drink. "Here's to your grandchildren!" This is good for increasing hydration. Ask the residents who should get the next toast. 3:30-4 pm--Sing-a-Longs. These are videos that have a Sing along with Mitch kinda feel. The patriotic ones are big sellers here. 4-4:30 pm--reading aloud the newspaper or the National Enquirer (not exactly fine literature, but it keeps everyone's attention) 4:30-5 pm--Book reading program. We advertise a book and each day read a chapter or two till it's finished. If it doesn't take the full 1/2 hour, we ask questions about what was just read. Takes us about 2 weeks to finish each book. Start with Charlotte's Web. 5-6:30 pm--dinner music with a featured artist each week--Glenn Miller or Count Basie weeks are most popular. I like the Andrew Sisters. 6:30-7 pm--Getting settled. This is mostly getting people out of the dining room and situated in the room with the big TV in preparation for the movie of the night. The drink and snack cart also comes in with them. 7-8:30 pm--Featured movie (previously advertised and discussed during dinner to increase attendance). The old black and whites are popular, so are the Judy Garland/Mickey Rooney ones with musical numbers. The aides come and remove people for PM care-they can return in their pajamas or go right to bed. 8:30-9 pm--sensual therapy. Hand massages, nail care and manicures. Soothing music. 9:30-10 pm--most are in bed by now. The die-hard fall risks are still up or back in their pajamas. We put in another movie and continue with the sensual therapy or hand out the PM nourishments and snacks and put on music. Want to know a neat trick I learned at a fall seminar? Fold up a white sweater and put it on a female resident's lap. They don't want to risk dropping it on the floor and will sit holding it for a long time. A baby doll or Bible also works sometimes (depending on the level of dementia). If you have some that no matter what you do, can't focus on the activity--try seating them near a pile of towels and pillowcases and ask them to fold them for you. That keeps some people busy a long time.

First, let me apologize if I repeat something already posted. I have not read all the previous posts. Palliative Care is a relatively new concept in our country; a country that is accustomed to fixing everything. We tend to white-wash illness and death, banishing our sick family members to the sterility of a hospital. Many are not comfortable with the ultimate defeat--death, albeit a perfectly natural ending awaiting us all. The first things to consider in a terminal illness situation are the wishes and expectations of the patient. Open communication is needed so they can make their own informed decision on how and where they want to die. The family needs to hear these things. The team (patient/family/healthcare workers) needs to work together toward the same goal--a comfortable and dignified death. Do they want to continue diagnostic testing, including bloodwork and vitals? Do they want aggressive treatment or just enough analgesia to remain comfortable? Do they want artificial hydration or nutrition? Do they want 02, even though hypoxic narcosis is a much more humane condition for the dying? Do they want to stay home or die in the hospital? Someone must explain these things in plain language so the patient and family can make informed decisions. In Palliative Care, there is something called The Doctrine of Double Effect that says, in essence, a patient can be given pain meds to control their pain, even though the dose may hasten death. I would venture a guess that many experienced nurses have been in the position of administering that last dose of morphine to a terminally ill patient with respirations at or below 8. I believe communication is the key in these situations. In a perfect world, people would all spell out their wishes in a Living Will and appoint a Health Care Proxy and NOT leave a fractured family to anguish over doing the right thing or not. The patient in the original post had no business in the ER, that was an unnecessary indignity that should have been handled by Hospice at home. Just MY 2 cents.

As far as visitors and excessive use of callbells and visits to the nurses station with questions: I've often considered posting a sign that says: If you have run out of conversation with your loved one, GO HOME. Do not entertain yourself by requesting the staff toilet, shave, reposition or medicate your loved one because you have become bored. Again, GO HOME. Really.

I remember another student nurse experience and hope this doesn't offend anyone here. I was all of 19, a student LPN. My instructor, a student friend and I stood at the bedside of a 30ish man as I prepared to do my first male catheterization. I had to talk my way through it, giving rationales and possible problems as I went along. Introduce myself, check the ID band, open the kit, expose the site, place the barrier, decide clean hand, dirty hand. Grip member at 90 degrees, swab meatus with Betadine. Now she asks me something and I have to answer. I swab again and notice something's happening down there. Oh, no, I start thinking. From the corner of my eye, I see he's kind of smirking. I swab again. Yep, full glory erection. Like a deer in the headlights I look up at my instructor and give her the Now, what? look. I don't dare make eye contact with my friend. Instructor says something about returning in a few minutes and turns her back (probably to hide the smile). There I am with a stranger's erection in my hand, my face beet red and I just let go. It hits his belly with a loud SLAP and my girlfriend bursts out laughing. I throw the sheet over the guy, gather all the supplies and flee. What does the patient say as I pull back the privacy curtain? "Oh, baby, don't go."

Recent policy change here: PICCs are placed by surgeons in the OR of our community hospital. Can be removed only by IV certified RN at bedside.

There was a little boy down the street and his parents wanted to name him Harley with Davidson as his middle name. They settled on Dallas. The little brother was Austin. Were they from Texas? Nope, just thought it would be "a hoot." Yep, that's just where I want to get my chuckles from, people's reactions to my children's names. Oh, boy . . .

Always do the right thing. This means different things to different people. I always take it as Let your conscience be your moral compass.

I had the hardest time with Maternal/Child nursing. And, like HarleyGirl, I can tell you why--I had absolutely NO INTEREST in Maternal/Child nursing. As one of the oldest students in the class, I got along well with the infamously difficult instructor. I explained my disinterest in the course matter and told her I would always be a geriatric nurse. She said one day one of my patients would have a visit from their family and a grandchild/great-grandchild would choke or be covered in a funny rash. Wouldn't Maternal/Child health come in handy that day? Okay, I saw her point but still struggled mightily through the semester. My favorite course was Nursing IV/Endocrine.

I was an LPN for 17 years. I had this one nutty RN supervisor for awhile who relieved an even nuttier day supervisor on my unit (LTC). One evening the other LPN on the unit looked at me and said, "What are we doing? Let's go back to school. Look, if XXXX and XXXX can be RNs, so can we." She made the assessment appointments, we met for breakfast and drove together to the college and 5 years later, I was an RN. After our first semester, 4 more LPNs and 2 CNAs at the facility started the program. All but one made it through. I encourage all my staff to continue their education. Don't let anyone spoil your dream with their own spoiled-grapes attitude. Be proud and keep on going. The time goes by whether you go to school or not, so do something constructive and get the degree. Come here for encouragement if you don't have the support you need in your job or circle of friends.

JBudd reminded me of a silly thing *I* did on the job recently. The DOH was in for the annual survey. I was 6 weeks into my new position as DON and feeling more than a little stressed with their barage of questions, requests for records, "quizzes," etc. At one point I was rummaging through my desk drawer for some file they wanted and my phone rang. I grabbed it and said in my professional phone-voice, "This is XXXXX, can you help me?" Talk about Freudian slips.

My guess would be that was on a very, very, very bad day.

Want to read a hilarious essay from an ER nurse? Check this Best of Craigslist entry out. It had me howling! http://www.craigslist.org/about/best/por/67309047.html

That's where the Medical Director comes in. It's up to the M.D. to rein in the rouge docs who think their time is worth more than anyone elses. If a doctor ever hung up on one of my nurses, the next phone call they would get would be from me. I have all their private numbers.

I think a "Continue Home Meds" order can be dangerous and leave the doc open to problems with misunderstandings, especially in my geriatric setting. Maybe it's okay for younger hospital patients with short stays. I'm in LTC facility and we (nurses) present the discharging doc with the current MAR and TAR. He/She then writes a prescription for each med that should be taken once the patient is home. If the resident is transferring to an Adult Home setting, they have to write scripts for OTCs, too. We legibly write the list of meds/treatments on the discharge form according to the paper scripts. If the patient is going home alone and I know they have visual problems, I make them a large-font list of their meds to post on their fridge, along with the times they have been receiving the meds while in our facility. We also make a copy of all the scripts now because of an ugly situation that occurred awhile back. The copy goes in the closed chart along with the Home Care Referral and signed discharge instructions copy. It's a lot of work, but better to prevent a misunderstanding and med error once the patient is home.

I agree with Bird2. As a floor nurse, duplicate documentation made me crazy. As a Clinical Care Coordinator I recognized the danger of duplication--the more places the same information was written, the greater the chance of a discrepancy in the patient record. And you just KNOW the state will find that discrepancy and grill you on it. Now, as DON, I'm able to do something about it. We've combined a lot of forms (I&O and meal monitoring, for example) so we're only writing things once. Weekly psych notes are referenced in the chart. The BP taken for 9 am Cozaar is enough. The 9 am Norvasc and Diovan have lines drawn through the BP boxes. Psych vitals for residents on antihypertensives have SEE MAR on the BP line.We're currently working on reducing the Admission Assessment forms from 12 (yes, 12) pages as a lot of the information is found elsewhere in the record. Unfortunately, as long as a injury of unknown origin is discovered, an investigation must be done to reasonably rule out abuse. I don't see that changing anytime soon. At every nurses meeting, I ask the staff about duplicate documentation and for their suggestions for streamlining the paperwork to give them more time with the residents.

The only time I've ever used controlled isolation with a resident was a lady with a stroke that left her with incessant chanting. With assessment and observation, we saw that her chanting escalated to almost fever-pitch when she was stimulated, whether by the TV, noise, lights, just about anything. She would quickly become utterly exhausted but unable to stop herself. She couldn't eat and lost weight. We adjusted her behavior by putting her in her room for periods of time with her back to the door. She continued to chant, but it slowed to a whisper after time. This was all documented in her careplan and nurses notes. She was served meals in her room to ensure she ate. It worked well for close to 7 years until she passed away.

Working in a nursing home is different than working in a supermarket. When you're short-staffed, the cereal boxes don't know any better. Our business is human life and unfortunately, mandatory overtime is sometimes required in order to ensure safety for the people in our care. We use a seniority list and everyone understands that when it's their turn to stay, they stay. This only happens about 4 times a year, thankfully. Our policy is at least 2 hours notice to call out for the shift. Less than that means no pay for the day. It is unfortunate that the staff with all the drama in their lives has made this policy necessary. We have 9 sick days per year, 3can be used for family illness (children mostly). I've sent people home who are obviously ill. I'd rather work at minimum staffing than compromise my resident's health.

On admission, we SUGGEST to the doc our normal bowel protocol: 2 days no BM--warm prune juice 3 days no BM--30 ml MOM no BM in the following 16 hours--Fleet enema If we use MOM twice in a month, we suggest the doc order a standing Senokot or Colace. One doc orders look like this: Percocet one with Colace 100 mg q4h PO prn--pain 5-10. For standing narcotic orders the protocol suggested by our pharmacy consultant is: Senokot-S 2 tabs at hs -if not BM in 24h--up dose to BID -if no BM in 2 days--Dulcolax 10-15mg at HS, then increase to BID -if no BM on day 3, add Dulcolax suppository I review the MARs at the end of each month and see if too many prn bowel meds are being used. Then I ask the docs to adjust the standing softeners or laxative orders. Hope this helps.

This is probably more than you're asking for but here goes . . . As with most problems, start at the beginning. WHY is this gentleman not eating? Look at his diagnoses and labs and see if they indicate a physiological problem (cancer/malabsorbtion). Does he have dysphagia and physically can't get the food down? What meds is he taking, could he be Digoxin toxic? Is he taking so many meds they're killing his appetite? Crushing meds is good for that. Does he have a zinc deficiency that's causing a smell/taste disturbance? What condition are his teeth and gums? Does he have chronic pain or constipation that's preventing him from wanting to eat? Once you rule out the physical problems, start on the emotional ones as previously stated. Depression will stop people from eating. Is he end-stage dementia and doesn't know how to eat anymore? Psych can help with that. I hesitate to throw more and more meds at people without considering all the above. In geriatrics, I consider all symptoms to be medication side effects until proven otherwise. I've never had any success with Marinol or Megace, either. Okay, now take a look at his meal offerings--is he overwhelmed by the amount of food on the tray? Does he hate the sight of puree/mech soft? Is he overstimulated by the crowd and noise of the dining room? As people age, they tend to lose their taste, what remains is their taste for sweets. Try all the suggestions made by the previous posters (I made notes to try on my unit, thanks!). Try drizzling maple syrup over meat, add ice cream whenever feasible to drinks. A big hit in my place are Creamsicle Floats--orange soda and ice cream around 3 pm. Keep trying and remember to document your efforts in the chart, esp. the careplan to show you're doing all you can. Hopefully, something will work and in 6 months you can post your success story for us.

I sit at those budget meetings and believe me, they aren't pretty. When the directive comes down NO OVERTIME, what is actually meant is, No Unecessary Overtime. On review of my staff time sheets, the worst overtime offenses are leaving a few minutes late. Every day. Enough people do this on a consistent basis and it adds up to an enormous waste of money. When your manager enforces Get in on time and clock out on time unless you're authorized to stay, she/he is serious. No one will question a nurse staying because of a call-out on the on-coming shift or a nurse staying because of a late admission. That can be justified and if the manager's a good one, they'll argue successfully for it. It's the 6 minutes here and 4 minutes there because someone stopped to grab a cup of coffee or chat with a coworker before punching out that kills the budget over time.