What besides the obvious do state inspectors look for in LTC?

[kstec, LPN]

I recently started at a LTC facility and they just got a new administrator and are trying to clean the place up. I've only been a LPN for about 18 months and primarily worked family practice for most of it. I worked as a CNA many moons ago so I have some idea of what the obvious things they look for but are wondering about the not so obvious. The unit I've been working on is getting better but still a mess. Yesterday in between medpass I decided to go through bedside tables. I found needles (unused), syringes, all types of dressings, neb tubing, neb tx vials, a prescription med for wound care that was dispensed 4/21/2006, tubefeeding tubing and the list goes on and on. Do you think that by cleaning some of them out, I save the facility some fine money? Also the MDS coordinator told me that we got tagged for leaving a resident in her geri-chair unattended. What is that about? Why is that different than having a resident in a wheelchair? Well any helpful hints would be greatly appreciated. Like I said I think I know the obvious but not the not so obvious. Thanks in advance.

[catlynLPN]

Here are some things that I see in the LTC that I work in that are so obvious you'd have to be blind to not see them.

Lack of mouth care

dirty fingernails

filthy refrigerators

filthy med carts and on the carts eye drops and nasal sprays mixed up together

one refrigerator being used for food and medicine and lab specimens, because the facility is too tight to purchase enough fridges to separate all those things.

Honestly, I don't know what keeps this place open.

I've tried to do some cleaning, on the fridge and med cart,

but it would take more than myself to get fingernails cleaned and give all those people proper mouth care.

It is just disgusting, but they stay open, always passing inspection.

[CoffeeRTC, BSN, RN]

First off...when you walk into the facilty or unit, how does it smell? That will start the ball rolling. What do the residents look like? How are they sitting in the W/C gerichairs? Does the place look clean?

Normally, before they even walk into the facility they will have a list of residents that they will want to automatically see. This list is based off of the QI which are pulled from the MDS. Ask if you can get a copy of your list or the Roster/ Matrix. This list will tell you who has a pressure sore, incontinace, cath, behavior issue, fall, restraint, etc.

As far as the mess....I pitch alot of stuff into the trash. Your pharm or facility should have a list of general exp dates for meds. If they need reordered...I do that then pitch the item if expired ( eyedrops, insulin, resp tx, IV supplies, etc) They will check dates on tubings, tube feedings, neb and resp tx etc. Date and inital all of your dressings and tubings or IVs that you hang.

They will look in the refrigerators on your unit too and might want to peek into the med rooms too.

Handwashing is a biggy too.

[Blackcat99]

I remember a med pass violation at an LTC in Calif. When the inspector went with the nurse when she gave meds, she didn't offer any water to the patients who didn't have any meds!!!!! How silly is that? I quess when you give meds you are suppose to give water to every single resident during your med pass even if they have no meds ordered????

[CoffeeRTC, BSN, RN]

Unless you had a hydration policy or identified that person at risk, I would have fought that one.

Make sure you are giving enough fluids with the meds too. Esp you fiber powders. We were hit on that one....not done per manufactures recomendation..

[Skeetersmom119]

First off...when you walk into the facilty or unit, how does it smell? That will start the ball rolling. What do the residents look like? How are they sitting in the W/C gerichairs? Does the place look clean?

Normally, before they even walk into the facility they will have a list of residents that they will want to automatically see. This list is based off of the QI which are pulled from the MDS. Ask if you can get a copy of your list or the Roster/ Matrix. This list will tell you who has a pressure sore, incontinace, cath, behavior issue, fall, restraint, etc.

As far as the mess....I pitch alot of stuff into the trash. Your pharm or facility should have a list of general exp dates for meds. If they need reordered...I do that then pitch the item if expired ( eyedrops, insulin, resp tx, IV supplies, etc) They will check dates on tubings, tube feedings, neb and resp tx etc. Date and inital all of your dressings and tubings or IVs that you hang.

They will look in the refrigerators on your unit too and might want to peek into the med rooms too.

Handwashing is a biggy too.

They look at those that have "triggered" in at least 6 areas of the QI report, or those that have not triggered at all, or maybe 1 or 2. I am also a Certified Dietary Manager, and I had the kitchen and documentation for7 years before becoming an LPN, and usually I could predict most of the charts that they pull. Watch the tube feeders, Dialysis patients, those under 50. Keep the I & O sheet up, MARS signed off, accurate amounts of sliding scale insulin recorded on the MAR. Make sure the thick liquids are noted, and that they do not have a water pitcher. Keep the problem families and residents happy LOL.

[Skeetersmom119]

I might add, I had my first survey as a LPN, and the dietician that was on the survey team at the building when I was a food service director was at this building too ! She is not a very nice person either. She kept looking at me with that "I know you from somewhere look", but I stayed out of her way LOL...We used to lock the kitchen doors to keep her from sneaking in... She also dabbles in nursing stuff that she doesnt know anything about LOL.

[CapeCodMermaid, RN]

You should be commended for being proactive and trying to clean up before survey.

A few items to look at in addition to what everyone else said:

PICC lines...neasure the length of exposed catheter on admission and weekly thereafter with measurements of the arm above and below the insertion site with documentation of the condition of the skin

Care plans..everything must match

Falls...make sure you have a documented intervention with each new fall

MD orders and progress notes...all have to be signed per regulation

GTubes...verify placement BEFORE giving meds...with air (no joke..a nurse at a place I used to work verified the placement with water!!kind of defeats the whole purpose)

Med pass...no APs or fingersticks in the hallways. Make sure your order and MAR matches exactly...don't give a multivitamin if the MAR reads multivitamin with minerals...alcohol gel cleaner between patients and washing after every 3-4

Wound care-daily documentation of the wound and periwound with weekly measurements

Name tags...don't laugh...you can get cited for this

Nebs...02..all tubing needs to be dated and if not being used in a plastic bag..not on the floor

If you have someone in a gerichair and the legs are up, make sure it's not a restraint or make sure it's well documented with an order, a consent and a care plan

Psychotropics---consents, and GDRs

The list is endless and every year they seem to focus on something else.

In my state the surveyors are going to start using digital cameras to 'document' what they see.....yikes!

Don't forget your CNAs. There is a great little book on survey prep for CNAs. Good ones will be worth their weight in platinum if the surveyors ask them questions and they give the right answers!

[st4wb3rr33sh0rtc4k3]

On Insulin. MOM, Tylenol, etc., that you open, put the date opened and make sure none of them have expired.

Know you math problems for medication administration. I had a colleague that was questioned about this.

Check name bands to make sure they are the right patient, even though you know them. And make sure they have a name band, or a picture in the MAR book.

Food that is not cold. Make sure everything is hot and that they have the right diet. They especially liked how even the RNs and LPNs helped pass out trays to the residents.

Do not take a break during meal time.

When I think I more that aren't mentioned, I will be back.

[st4wb3rr33sh0rtc4k3]

Okay, lol

Introduce yourself.

Promote privacy. Knock on the door before you enter. Close the door or curtain, and tell them why you are doing it.

Oh please, and the call light within reach.

[txspadequeenRN, BSN, RN]

i know that you are a don and after reading this and comparing it to my place of employment ...i am surprised we are not shut down. i think that in light of the missing stuff we really care about our residents and try to give good care but there are some sloppy nurses. it drives me crazy that no one charts their prn's. of course you know if they compare the narc sheet and the prn sheet and the documentation is not in place your in deep doo doo. nothing is dated when opened or when replaced (neb mask or humidified air bottles).

oh and the charting..oh my goodness the awful charting...:omy:

let me give you and example of charting on a patient that fell and had to be sent to the hospital..this is no exaggeration either

pt fell sent to er , wife and don notified.

well when i got this patient back he had multiple open oozing wounds in need of dressings , multiple bruises a gash in his head.....he had seven wounds that i had to measure and document on. i cant even imagine if state would get a hold of that....

i guess i just needed to vent.. to the op make sure you are not guilty of sloppy nursing....cya

you should be commended for being proactive and trying to clean up before survey.

a few items to look at in addition to what everyone else said:

picc lines...neasure the length of exposed catheter on admission and weekly thereafter with measurements of the arm above and below the insertion site with documentation of the condition of the skin

care plans..everything must match

falls...make sure you have a documented intervention with each new fall

md orders and progress notes...all have to be signed per regulation

gtubes...verify placement before giving meds...with air (no joke..a nurse at a place i used to work verified the placement with water!!kind of defeats the whole purpose)

med pass...no aps or fingersticks in the hallways. make sure your order and mar matches exactly...don't give a multivitamin if the mar reads multivitamin with minerals...alcohol gel cleaner between patients and washing after every 3-4

wound care-daily documentation of the wound and periwound with weekly measurements

name tags...don't laugh...you can get cited for this

nebs...02..all tubing needs to be dated and if not being used in a plastic bag..not on the floor

if you have someone in a gerichair and the legs are up, make sure it's not a restraint or make sure it's well documented with an order, a consent and a care plan

psychotropics---consents, and gdrs

the list is endless and every year they seem to focus on something else.

in my state the surveyors are going to start using digital cameras to 'document' what they see.....yikes!

don't forget your cnas. there is a great little book on survey prep for cnas. good ones will be worth their weight in platinum if the surveyors ask them questions and they give the right answers!

[CapeCodMermaid, RN]

Don't get me started on sloppy charting. We had a patient fall..I was on the floor at the time and saw every assessment and intervention the nurse did (of course I was there helping and not just watching). The patient was stabilized and sent to the ER. I came back a few hours later and the note read "Pt found on floor, sent to ER, MD and wife notified." I found the nurse and asked her to review all she had done for the patient. She told me and then I showed her the note. Take credit for what you did.