Thursday, November 13, 2008
As far as that something special I promised, I am going to put up a NAB test that I constructed myself when I was studying. I found that I can learn and retain information better if I act as if I'm having to teach it, so a mock exam was in order. I don't recall any of the questions I made actually showing up on boards, but it should serve its purpose well and it will save you however much you might otherwise pay for a practice test (I've seen them go for $15 to $75 apiece). Look for it to come out either tomorrow or saturday.
Monday, November 10, 2008
Sunday, October 26, 2008
Wednesday, October 15, 2008
Tuesday, October 7, 2008
Bad news: Once again, I'm a week late getting them out. I promise to have next month's slides up by November 1, or I'll do something good to make up for it.
Tuesday, September 30, 2008
Thursday, September 25, 2008
Tuesday, September 23, 2008
-Hydrogels are the way to go for wet-to-dry; they work well for most applications
-Hydrocolloids are not appropriate for acute care, but might be okay for nursing homes
-Acrylics only have to be changed every 7 days (can sometimes last even longer)
-Foams are best for shallow wounds on the extremities; don't use on the sacrum
-Aliginates are used for lots of drainage
-Hydrofibers absorb 3x more than aliginates
-Xenaderm is good for progressive stage I/II ulcers
-Betadine keeps necrotic tissue dry and is best for heels and toes
Monday, September 15, 2008
-Arterial ulcers need to be kept dry, preferably with Betadine.
-Venous incompetence with lymphedema: redness is most often reactive erythema and not infection, so don't give antibiotics.
-Betadine keeps necrotic tissue dry and is best for heels and toes.
-If there is a yellow ulcer, the red spots that are speckled throughout it are hair follicles and this indicates that it is a stage II.
-Heel ulcers are 100% preventable.
Friday, September 5, 2008
For the bathing slides, you need to also access this page to find out most of the information listed:
Friday, August 15, 2008
Sunday, August 3, 2008
Thursday, July 24, 2008
The facility must prevent pressure ulcers and effectively treat those that are present.
Pressure ulcer prevention must be promoted. Existing pressure ulcers must be treated appropriately, and the development of additional pressure ulcers must be prevented as well.
Common Reasons for Citing F314:
The lack of documentation and monitoring is the most common reason this tag is cited. Other causes include the care plan not being individualized for the resident with a pressure ulcer, failure of the communication process between CNA and nurse regarding the development of pressure ulcers, the lack of dietary intervention, failure of the nurse to notify the physician, the lack of pressure relieving devices even if not ordered, wound care not being provided per physician order, the nurse’s failure to maintain clean or sterile technique as indicated, using a shearing motion while turning and repositioning the resident, and providing wound care without cleaning up incontinence beforehand.
With the lack of documentation being the biggest factor with this citation, frequent chart audits are essential. It is also essential that nurses providing wound care be observed for their compliance with physician orders and established guidelines. Some facilities have had great success by having weekly skin rounds, in which an interdisciplinary team (including at a minimum the skin or wound care coordinator, MDS coordinator, DON or ADON, and dietician) shadow the treatment nurse as wound care is provided. This team based approach provides the opportunity for all of the above-mentioned audits to be done in a timely and efficient manner. It is also necessary to have an effective system in place for addressing CNA-nurse communication.
Thursday, July 17, 2008
Tuesday, July 8, 2008
Monday, June 30, 2008
Friday, June 27, 2008
1. Sliding scale insulin is no longer considered appropriate for the nursing home setting. I will do some research and write more about this later.
2. Nursing homes are an excellent place for BSN students to do nursing management/leadership clinicals. This is something you should consider doing, as it is a great recruiting tool for RNs.
3. When interviewing licensed nurses, be sure to ask some clinical questions to make sure that their level of competency is where you want it to be at. It is suggested that you ask these 3 questions, at a minimum: (a)What are the signs and symptoms of heart failure, (b)How would you recognize if someone was hypoglycemic, and (c)What would you do if someone was having a stroke in progress?
4. Post the list of emergency stock drugs by the phone, so the nurse doesn't take an order for a med that can't be administered right then. It will also save a nurse the time needed to retrieve the list from wherever it is usually kept, which also keeps her from looking incompetent in the doctor's eyes.
Monday, June 16, 2008
Thursday, June 5, 2008
Friday, May 30, 2008
Nursing home surveys are nothing to be paranoid about, unless you're trying to hide your substantial noncompliance. Survey protocol is clearly spelled out in the State Operations Manual. It should be no mystery who gets interviewed, because the manual tells you. "But the surveyor's don't do things by the book!", I can hear someone cry. If they don't, then appeal it. That's what IDR and the appeals process is for. The reason that deficiencies happen is primarily because nobody knows the rules of the game called survey. As I cannot emphasize enough, TEACH YOUR STAFF THE STATE OPERATIONS MANUAL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Of course this is a problem if you don't know it yourself. When a week long DON orientation attempts to cover everything about survey in 45 minutes, and the required text for virtually every AIT program in the country doesn't even mention the word 'survey', it's not entirely your fault. But if you haven't been taught it, you need to learn it for yourself. As anyone who has ever tried to read the watermelon book cover to cover can tell you (myself included), it's one hell of a boring book. Perhaps you could try this instead: Get the forms used in the quality indicator survey and do mock surveys through QAA committee with them. You will learn the rules as you go along because the contain the relevant F tags and the critical elements necessary for demonstrating compliance with them.
You can be paranoid about state if you want, but it's a waste of time and energy you probably don't have. If your facility is not survey ready when they walk in the door, there is only so much you can do to fix things while the surveyors aren't looking. Doing well on survey takes staff education and frequent mini mock surveys conducted over the course of the entire year. Waiting until you're already inside the window is uselsss.
Monday, May 26, 2008
Tuesday, May 20, 2008
Services provided or arranged by the facility must meet professional standards of quality.
All services performed in the facility must conform to generally accepted standards of clinical practice. These standards may come from textbooks, current journals, position statements by such organizations as ADA, AMDA, ANA, etc., or clinical practice guidelines published by AHCPR.
Common Reasons for Citing F281:
Improper disposal of controlled substances
Failure to secure controlled substances
Leaving medications at bedside
Failure to assess for dehydration issues
Failure to carry out physician orders
Failing to add new interventions after a fall
No care plans or lack of care plan review for resident care issues
Not monitoring or assessing dialysis access site
Failing to date multidose vials when first opened
Pre-pouring of medications
Improper documentation of medication administration
Frequent education is necessary to make sure that nursing staff understand the standards to which they should be practicing under. Explanation of rationales is vital in this aspect. Working alongside nurses during medication passes is a useful technique for ensuring compliance with this tag and has the potential to improve staff morale if carried out in an appropriate manner. Having generic care plans available for frequently missed areas of care is another useful idea. Frequently missed areas include safe smoking, constipation, weight loss, hydration, fluid restriction, accident prevention and falls, skin breakdown, and hemodialysis.
Sunday, May 18, 2008
Thursday, May 15, 2008
In the vast majority of nursing homes, CNAs are taught from the immensely popular How To Be a Nurse Assistant. Published by the American Healthcare Association, it is one of their best sellers (right after their reprint of the CMS State Operations Manual). Irregardless of how good the book is, nurse aides quickly find it to be useless in the real world. Despite all of the skills taught in the book, it doesn’t adequately cover the three things that the average CNA spends 90% of their time doing: skin care (turning, positioning, changing, bathing), providing assistance with eating, and dealing with psychosocial issues.
It is no secret that training programs for nurse aides are not only irrelevant to what really goes on, but are also of an inadequately short length. Whatever notion you may have to the contrary, the CNA is not an unskilled worker. Although some of the physical tasks probably would be considered menial, that is not the point here. As Lori Porter pointed out in her autobiographical Everything I Learned in Life...I Learned in Long Term Care, a nurse aide has the power to either promote a resident’s physical, mental, and psychosocial well-being, or completely destroy it and take that individual’s last shred of dignity away from them.
Either we forget (or simply have never realized) the enormous power we have entrusted to these folks – power that oftentimes goes unchecked. If we are to fulfill our legal obligations as nurses and/or administrators to maintain the health and welfare of our residents, it is simply incomprehensible to think that we would delegate this enormous task to unskilled workers. Thus we must transform the workforce, which can be achieved in one of two ways.
The first way is to change the way that CNA classes are conducted. Consider lengthening the course from two weeks to three weeks. The current practice is to have the students spend a week in class, then a week on the floor. What I suggest is that you combine class time with floor time. After three days or so in the classroom dealing with non-clinical topics, slowly introduce the students to the residents. Let them know what is going on with them from a medical and from a psychosocial standpoint so that they can truly see in action the conditions they are learning about. Have the students spend time on the floor during its busiest times, and then during the lulls have them to return to the classroom to talk about clinical issues. Don’t be limited by the textbook – allow the student’s minds to go above and beyond the norm. It seems that every nursing home wants well trained staff but they don’t want to put forth any effort to achieve that dream.
Although some corporate owners and administrators may balk at this approach, citing increased costs, it is actually a worthwhile investment. It is common knowledge that the vast majority of CNAs quit soon after being hired so it is prudent to keep a proverbial safety net under them for an extended period of time. With this paradigm in place, the students will have a supporting framework when things get rough. During the latter part of the second week or the early part of third would be an excellent time to begin peer mentoring.
Tuesday, May 13, 2008
Saturday, May 10, 2008
Friday, May 2, 2008
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.
It is the nursing home’s responsibility to make sure that residents either get better or stay the same (within the resident’s right to refuse treatment), within the limits of the resident’s medical condition and/or the normal effects of aging.
Common Reasons for Citing F309:
The most common reason this tag is cited is for failure to reposition. For example, a resident is observed sitting in the same position for 3 hours, even though they are care planned to be repositioned every 2 hours. Another common reason for this tag is missing lab work. Other reasons that have been used to justify this citation include failing to properly manage pain, noting that residents are not wearing TED hose that has been care planned, failure to protect fragile skin, and lack of foot pedals when their use is obviously necessary. F309 is a sort of catchall citation and is frequently cross referenced to other tags.
Because of the vague nature of F309, it is often difficult to adequately plan for this. Missing lab work can be oftentimes be prevented by requiring nurses to maintain a log of lab work or having all labs being coordinated through just one individual, usually a RN supervisor or administrative nurse. Issues with repositioning can be handled by educating and monitoring staff on its importance. Some facilities have attempted to tackle persistent repositioning problems by keeping underpads in three different colors and requiring direct care staff to change the existing pad to one of another color every two hours. The resident will be repositioned in the process of the pad change, and it becomes rather easy to monitor staff compliance by just checking to see what color the pad is. The other issues can be addressed by frequently walking around and observing how residents are cared for.
Tuesday, April 29, 2008
Sunday, April 27, 2008
Wednesday, April 23, 2008
is the form that surveyors use to ensure compliance with the Life Safety Code. Perhaps you could find it useful when preparing for inspections.
Thursday, April 17, 2008
2. There are four primary goals of behavior: Power, revenge, attention, and display of inadequacy
3. http://www.paraprofessional.org/publications/coaching_supervision/ has "Coaching Supervision" pdf files for free (Normally $99 through AHCA)
Tuesday, April 15, 2008
Wednesday, April 9, 2008
Thursday, April 3, 2008
Monday, March 31, 2008
Saturday, March 29, 2008
"On another note, this same study revealed another "secret." In war days in the concentration camps the prisoners were subjected to various types of torture. Among these was that they were awakened every 2 hours during the night and forced to stay awake for about 10 minutes and then allowed to go back to sleep. This severely disturbed their sleep patterns and thus, made them clumsy and confused during the day due to lack of proper REM sleep. Hmmm, is this what we are doing to our elderly? Is this part of the reason for so many falls and inappropriate behaviors?"
Does the way your facility take care of residents actually cause more harm than good? This is something to really think about.
Wednesday, March 26, 2008
A most powerful excerpt from "Everything I Learned in Life...I Learned in Long Term Care" by Lori Porter
Although this book has been out for some time, I just got the chance to read it last night and I was really touched by it. I especially appreciate the above-mentioned quote so much that I plan on printing up a copy and sticking it in front of my desk just to remind me how much power I really do have working in long term care. I think you should print off a copy too, and make sure that no one in your nursing home forgets that power either.
Tuesday, March 25, 2008
(2) Recruit volunteers to come in and write down the stories of resident's lives that they dictate to the volunteers. Share these stories with staff so they realize that the resident is a person with a rich, vibrant history and not just some inanimate object to feed, change, and bathe.
Wednesday, March 19, 2008
Tuesday, March 18, 2008
ANYTHING STORED ON FLOOR
DENTED OR SWOLLEN CANS NOT STORED SEPERATELY
INSECTS OR DROPPINGS
STREAKS ON WALLS ALONG SHELVES
LACK OF FIRST IN, FIRST OUT ROTATION
OPENED FOOD THAT IS UNSEALED AND/OR UNDATED
BULK FOODS IN CRACKED OR PEST-VULNERABLE CONTAINERS
UNUSUALLY HIGH OR LOW TEMPERATURE IN FOOD STORAGE AREA
REFRIGERATOR TEMPERATURE >41 DEGREES FAREINHEIT
HIGHLY PERISHABLE FOODS USED AFTER THREE DAYS OF BEING OPENED
(This means foods that are animal derived and/or high in protein)
EGGS IN UNBROKEN SHELL USED 4-5 WEEKS AFTER PACK DATE
RAW ANIMAL FOODS LOCATED NEAR OTHER ITEMS
FREEZER TEMPERATURE >0 DEGREES FAREINHEIT
FROST BUILDUP IN FREEZER OR EVIDENCE OF THAWING
SPILLS IN THE DAIRY CASE
DIRTY SHELVES, FLOORS, OR WALLS
CROWDED STORAGE SPACE
HOT FOOD HELD FOR MORE THAN 30 MINUTES BEFORE SERVING
ICE IN CONTACT WITH FOOD
HOT FOODS HELD <135>180 DEGREES
COLD FOODS HELD >41 DEGREES
LACK OF HAND WASHING/SANITIZATION
IMPROPER UTENSIL USE OR LACK OF CLEANING
IMPROPER OR LACK OF CLEANING OF EQUIPMENT AFTER USE
LACK OF COVER DURING TRANSPORTATION
FOODS TRANSPORTED NEAR SHOES OR FLOOR
Saturday, March 15, 2008
Friday, March 7, 2008
"Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?
Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?
Did somebody notice I did it, i.e., am I recognized for my contribution?"
Can every single employee in your nursing home, administrator on down to the lowliest part-time laundry aide, answer these questions in the affirmative?
Monday, March 3, 2008
Friday, February 22, 2008
1. "Throwing money at a problem usually only makes it worse"
2. Crisis management is bad. It is used to demonstrate that something is getting done. It causes processes to break down and for people to make shortcuts in order to save time. "Quick productivity takes precedence over quality".
3. "The fear or inability to say no in an organization is enormously destructive to any QM initiative. It immediately creates distrust and stifles productive feedback. Employees are fearful of being fired. Exposing any weakness or faults labels the employee as a troublemaker. Employees are then very distrustful of any management scheme that talks about empowerment. If they don't see empowerment or trust in action, they will correctly decide that it doesn't really exist. If their evaluations are based on the quantity of work performed, process improvement will be seen as a waste of time. Their view is, 'Why spend the time required to fix processes?' For them, management's over-focus on short-term tasks or projects give visible (but false) evidence that real work is being done."
I find this last item particularly true. It is interesting that this comes from a chapter about quality in military medicine, as I once heard someone say that calling CNAs the 'front line' makes it sound as if we are fighting a war. Perhaps we are.
Thursday, February 21, 2008
Saturday, February 16, 2008
Tuesday, February 12, 2008
Monday, February 11, 2008
Monday, February 4, 2008
Thursday, January 31, 2008
Monday, January 28, 2008
1. Now that you've been here for a while, how do we compare to what we claimed to be when we hired you?
2. What are we doing that's good? Who here has been helpful to you?
3. At the last place you worked, what were they doing that we could do here to make things better?
4. Is there anything here you don't like? What can we do to make things better?
After this meeting, continue to meet with your staff. If the employee has any answers to ideas 3 or 4 that deserve recognition or reward, make sure they get it.
Saturday, January 26, 2008
Friday, January 25, 2008
You can check out the results of the pilot projects and validation studies, which are now finished.
Tuesday, January 22, 2008
is one management consultant's advice to all corporate executives. Although not directly applicable to nursing homes, or even healthcare, a lot of the same principles still apply, like, "If you want to see things change immediately, stop being an asshole". Check it out and apply it today.
Sunday, January 20, 2008
Friday, January 18, 2008
Thursday, January 17, 2008
1. After May 23, 2008 do not use the old legacy codes with your NPI # when submitting claims.
2. Due to a computer glitch that some of the fiscal intermediaries had, if you had denials on a no-pay bill at the end of the fiscal year, don't split it but instead resubmit.
3. AAPC offers CEUs to certified coders who complete any webinar or course sponsered by CMS or a carrier.
4. MDS 2.0 has had revisions as follows: (Chap. 3)I2J, I3, K2A, K3, L1E, M4, M4G, M5E, (App B).
5. MDS 3.0 will have a conference in Baltimore on January 24; it will also be presented via conference call at the same time. They will discuss the draft version and how the pilots went.
6. MACs (Medicare Modernization Act Contractors) will replace FIs and carriers. Meridian Services, Trailblazer, Wisconsin Physician Services, Highmark, and Palmetto have been awarded contracts for regions 3, 4, 5, 12, and 1, respectively. MACs for regions 2, 7, and 13 have not yet been awarded.
7. The therapy cap still remains at $1810/yr, but Congress is allowing the exception process to continue out through July 31, 2008.
8. Next Open Door Forum conference call will be on February 28, from 2-3 EST.
Monday, January 14, 2008
1. Have there been any near-misses that nearly resulted in resident harm?
2. Have there been any incidents recently where a resident was harmed?
3. What things do you think will cause another resident to be harmed?
4. What can we do to prevent the next adverse event?
5. Can you think of a way the system here doesn't work?
6. What specifically can administration do to make the work you do safer?
7. What are we doing that works?
has some really nice QI stuff. The website's title is "Problem-Oriented Best Practices". Topics include ethics, geriatric syndromes, nutrition, organization and administration, medication prescribing practices, and preventive practices. Good stuff!
Friday, January 11, 2008
1. Ask the employees what is going great on their unit
2. Bring an employee to the daily stand-up (also known as department head meeting), introduce them, and spotlight their successes
3. Let the residents know how good you know the direct care staff is -- be specific
4. When you speak at staff meetings, base everything around a story. If you need to talk about the importance of fall prevention, for instance, begin with the story of a resident who suffered undesirable consequences as the result of a preventable fall.
5. Have a communication board on each unit. Each week, have a white piece of paper titled, "What's Happening This Week". Keep it factual, short, and sweet. To quote Quint Studer from page 224 of Hardwiring Excellence, "We learned that employees define quality communication in terms of quick wins on what they really need to know about. Newsletters that feature executives in suits just don't do it."
Tuesday, January 1, 2008
http://deptets.fvtc.edu/nursing/index.htm is a online video based CNA course. This is a great resource for new CNA classes or for staff development.