RCM looking for organization in my life!

LTC_LNHA · Jul 6, 2017

It all depends on your responsibilities and supports...my experience is in a 35 bed medicare SNF and one 60 bed LTC with heavy care residents. I was not a nurse manager but QA person.

Write down on a calendar DAILY falls, new skin areas, incidents, admissions, discharges, hospitalizations, medication errors, and any relevant things.

Keep a living to do list separated by resident related/acute need AND strategic. I don't leave work until the resident related/acute need is completed. I work on the strategic when I had time (ha!).

I started with a clinical review of every record to ensure acute charting was completed sufficiently, order changes made on the MAR and responsible part notified, acute changes addressed, care plan changes made if needed, etcetera. ALWASY review all shower documentation to ensure all residents got their baths, narcotic count of ALL areas (carts, med rooms, med fridges, ekits, ANYWHERE THERE ARE NARCS), BMs per your facility protocol, and any 24 hour sheets the nurses and/or CNAs use to communicate between shifts. I made notes on a roster sheet I made that I took with to morning meeting so I could report to the admin/don/MDS coordinators all acute changes, residents on ATB, post fall documentation, status of skin areas, medications changes, behaviors, etcetera. Check all appointments and make sure transport was scheduled. Review all weekly labs especially cumodin orders to ensure compliance and notifications. During my review, I created to do lists for the unit floor nurses that they had to complete by the end of the day (e.g. notify X res family of the med change, need f/u on the no BM, res Y needs a shower today - if ref notify doc, family, and care plan, etcetera). I made boxes on my daily report sheet that I used before I left each day to check to make sure the floor nurse completed the required items or proceed to have the next shift nurse implement if appropriate.

I kept a binder with a copy of all GDRs, psychotropic and hypnotic medications, and dx that I reviewed with each batch of GDRs from the pharmacy consultant, made comment, and faxed to physical and f/u as needed depending on physician response. I found it handy to keep in this binder a list of physician visits to and ensure they are completed and the progress note makes it back to the hard chart. I also kept a list of all residents' diets/fluid restricts. I kept a list of weekly/monthly weights and all skin areas with current treatment regime and past two week measurements with dr/family notification that I audited weekly to ensure the weekly wound measurements were completed and the floor nurse is initiating notification for no improvement or worsening. I kept a list of residents with restraints, alarms, positioning devices, enabling devices, and wander guards that I audited myself weekly to ensure they were in place and still appropriate for care plan. Always have a list of cumodin residents and DOUBLE CHECK THE FLOOR NURSE! I also kept annual and monthly lab notes to ensure I checked them weekly with the daily/weekly lab schedule. I updated this binder daily with any changes to the residents plan of care and used this as my double check for care plan, doctor order/notification, and family notification.

I was responsible for monthly POS - keep a copy and fax/mail to physician discarding your copy upon receipt and update of the MAR/TARs. Always make sure this makes it to the hard chart ASAP - state surveyors use these religiously to compare MAR/TARs to physician orders.

I was responsible for performance reviews, scheduling (daily - thank god for our scheduler that handled the biweekly schedules!), discipline, and new hires. I demanded the office manager provide me by the first of the month any staff due for reviews in the next month, distributed the self evals ASAP with a DUE DATE a week prior to the review due date. I tracked this on my calendar and completed over the phone if they failed to complete by the due date. I reviewed the daily schedule after morning meeting. Keep up on discipline. I reviewed time card punches daily (well really I took them home and reviewed them Sundays with the upcoming scheduling and logged absences and tardies). Do your attendance and other disciple as fast as possible relative to the infraction and consistently. ALWAYS keep a copy of the discipline form for your records since the HR staff may loose or fail to file it...your need to be prepared for an unemployment hearing or legal case and if its not documented it did not happen. I wrote up the disciple forms and kept them in my calendar until I gave them, so they were really in the way. Scheduling was a train wreck so I really have no advice. Always make sure you keep a spread sheet with the current census, historic pay period census, hours worked form the business office, and calculate PPD versus budgeted. Always make sure you NEVER go over the budget PPD in your pay period.

Admissions/readmissions - review the chart ASAP to ensure all assessments were done by the nurses with the initial admit/readmit assessment done by the RN NOT LPN per state laws. Triple note the admission orders, update (or create) the acute care plan, and make sure all appoints were scheduled as needed.

Discharges - review the chart ASAP and ensure all areas completed (pharm notification, items returned, death certificate completed or discharge forms completed, narcs destroyed per your facility protocol, nurses notes closed out); close the record.

Accidents, incidents, falls, skins, weights, medicare, restorative, position/enabling devices devices, restraints, QAPI/PIP, wander guards (or CCDI assessments), care plans, and POSs. Family and physician notification and response done time on the incident report and in the nurses notes. Review and keep a QA log weekly with f/u for falls, incidents, skin areas, and other acute issues for at least two weeks. Skins and weights needs to be addressed with changes made by the RD and MD as needed but at least notification biweekly with no change and immediately/weekly with worsening. I tracked this a QA form the corporation created. Medicare, restorative, positioning/enabling devices, restraints weekly to ensure care plans are accurate and the residents is properly reviewing services to promote the highest level of well being. Always document in the IDT notes, "IDT team met to review incident/restorative plan/LOC/skin area/weigh loss. Note outcome of discussion. Singed"

Double noting - make sure the third shift nurses are doing it - create a log for them to write down what the double noted and collect it daily to compare to your master lists for updating.

Supplies - audit them as much as your responsible to ensure the nurses and aides have adequate amounts.

Audit sheets for everything to ensure compliance and adequate care.

Keep your QA materials and notes for at least two years for your records to support what you did!

Good luck, and I hope this helps! You will do great, I'm sure!

AlishaSuperNurse · Jul 6, 2017

Thank you so much for taking the time to make these detailed ideas. You have helped me so much, thank you, I can't wait to start implementing this list!