Setting the Nursing Home on Fire

Policy Guidelines Online

2009-03-22T17:32:00.000-07:00

These two websites have policy and procedure manuals that you may find useful for developing your own.

http://nursing.uchc.edu/unit_manuals/

http://www.gplan.com.au/index.php?action=view&view=14273&pid=13761
(Scroll down to the RACF Clinical Resource Manual)

Inservice materials: Enteral nutrition care

2009-03-22T15:30:00.000-07:00

Rather than develop a slideshow, here are links to sites that will help you create your own staff development session for licensed nurses on enteral nutrition care.

http://www.grs.scot.nhs.uk/instantKB13/FileRedirect.aspx?FileID=1405

http://www.free-ed.net/sweethaven/MedTech/NurseCare/GastroNurse01.asp?iNum=42

http://allnurses.com/general-nursing-discussion/peg-tube-residual-356852.html

http://www.dbh.nhs.uk/Library/Patient_Policies/PAT%20T%2016%20v.2%20-%20Management%20of%20Patients%20following%20PEG.pdf

http://www.gplan.com.au/content/Document/RACF%20Resource%20Manual/Percutaneous%20Endoscopic%20Gastrostomy%20Clinical%20Management%20Flowcharts.pdf

http://www.virginiageriatrics.org/consult/Peg_tube_decisions/index.html

http://www.ambpeds.org/site/sp_int_groups/PHM2005/Troubleshooting1.ppt (for pediatrics but still has some valuable information on the latest research)

http://www.southbirminghampct.nhs.uk/_services/elderly/policies/enteral_feeding_nov07.pdf

http://210.125.93.14/lecture/PDFGuides/HCP24.pdf

QA/QI tools

2009-03-22T15:25:00.000-07:00

The Kansas Foundation for Medicare Quality has redesigned their website and now offer better access to the QA and QI tools they have available at http://www.kfmc.org/providers/nh/tools/index.html. The ADL decline section has some good stuff on restorative nursing, and there is also everything you need to set up a skills fair for staff development.

NAB Practice Exam

2009-02-09T11:06:00.000-08:00

The NAB practice exam I wrote is available at:
www.scribd.com/doc/8570144/Nab-Review

Finally back

2009-02-09T11:02:00.000-08:00

It's been about three months since I've blogged. I've been extremely overworked and also questioning if I want to stay in this insanity known as long term care. Fortunately, I've received a number of very supportive emails from some previously unknown followers of this blog and have decided to get to back to blogspot. Nursing homes are still very far from ideal, much less perfect, and I want to help change that.

Everytime a CNA becomes a NHA, an angel gets its wings

2008-11-13T09:40:00.000-08:00

I very rarely talk about myself, but I am going to make an exception just this once. I got my administrator's license!!! I went through the process in Michigan, because if you are a RN you don't have to meet any other requirements besides passing the state and national licensure examinations. I probably won't be running a facility anytime soon as I got the license primarily for enhancing my ever-growing list of credentials and qualifications.

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.

Once again, slides are late

2008-11-10T08:46:00.001-08:00

MDS inservices for both CNAs and LPNs is available at http://www.parragonhealth.com/slides.htm. They are over a week late, so watch out for the good thing I have promised.

All about IDR

2008-10-26T20:06:00.000-07:00

There are two processes in place for challenging surveyor findings: formal appeals (which is used primarily for getting rid of civil monetary penalties) and informal dispute resolution. Informal dispute resolution is used primarily to get F tags taken off the record when the allegation of deficiencies doesn't actually represent an actual deficiency. It can also be used to challenge the scope and severity of quality of care deficiencies. It cannot used to challenge deficiencies on a follow up survey that have been cited on a previous survey, for scope and severity on F tags that do not fall within the quality of care domain OR represent an immediate jeopardy, to challenge remedies levied by the state or federal government, procedural violations on the part of the surveyors, or alleged inconsistency in the way that two different facilities were surveyed. In order for an IDR to be successful (and they rarely are -- less than 20% of the time), you have to either show that the alleged deficiency is not actually a violation (although the state survey agency may label this as a procedural violation and then disqualify your claim) or that there is documentation to support the facility's position that was not reviewed by the surveyor at the time.

NHA without AIT

2008-10-15T19:18:00.000-07:00

If you want to become licensed as a nursing home administrator, almost all states require that you have a bachelor's degree and complete an administrator in training program, which is a 6 to 12 month preceptorship with an experienced administrator, all before you are allowed to take the state and national boards. There are two states that do not require an AIT for licensure, just a bachelor's degree OR licensure as a RN: Illinois and Michigan. A third state, Missouri, has relatively lax standards for licensure but they reserve the right to require an AIT if they think it is necessary.

Good news and bad news

2008-10-07T20:48:00.000-07:00

Good news: This month's powerpoint slides are up at http://www.parragonhealth.com/slides.htm. The topic this month is skin.
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.

Life Safety Resource

2008-09-30T15:26:00.000-07:00

While trolling the web, I came across a very interesting document -- a fire and life safety toolkit. It has everything you might possibly need to prepare for a LSC survey. It's available at:
http://www.kahsa.org/content_new/pdfs/Toolkits/FireSafetyPreventionToolkit.pdf

Another long term care blog! Yay!

2008-09-25T14:13:00.000-07:00

A DON is blogging about her work at http://skillednursingthing.blogspot.com/. I really like her take on things; have a look sometime.

Wound care wisdom, part deux

2008-09-23T20:15:00.000-07:00

Here are some quick tidbits on dressing types.
-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

Wound care wisdom, part 1

2008-09-15T14:22:00.001-07:00

-Juven is better than Boost or Ensure for residents with low albumin levels, and can be mixed with near anything, thus increasing compliance.
-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.

New Slides are Here

2008-09-05T14:53:00.001-07:00

The September staff development slides are finally up at http://www.parragonhealth.com/slides.htm. I apologize for taking so long to post them, and also for not writing any blog entries in a while. It's been a crazy month.

Note:
For the bathing slides, you need to also access this page to find out most of the information listed:
http://www.nhcqf.org/QI_Services/NursingHomes/Workshop4/Bathing_Without_a_Battle_Handouts_0506-541.pdf

Book Review: The Principles of Health Care Administration

2008-08-15T10:52:00.000-07:00

I've finally found a book on nursing home administration that I finally like. If you've seen my reviews on amazon.com, you probably know that I absolutely loathe James E Allen's Nursing Home Administration. I was at a used book store in Nashville on monday and I found a copy of Winborn Davis's The Principles of Health Care Administration for only $5, which is great because it sells for $103 new -- I think that's just a bit too much. The book is divided into four chapters, one for each of the four NAB domains. It almost reads like a commentary on the State Operations Manual because most, if not all, of the F tags are discussed at length. The chapter on financial management needs more practical advice on how the business office should be run, but other than that I was thoroughally impressed. I think it would be the perfect AIT text or study guide for the NAB boards. Although it's out of print on amazon, it can still be ordered here for $98.50.

New nursing home blog

2008-08-03T21:32:00.000-07:00

Nursinghomesurveyor.com is a new blog that shows a lot of promise. Check it out!

New Staff Development Slides Availble

2008-08-03T21:30:00.000-07:00

This month's staff development slides are now available at http://www.parragonhealth.com/slides.htm. The topics are "Feeding the Hard to Feed" and "Renal Failure".

F314: Pressure Ulcers

2008-07-24T13:56:00.000-07:00

Requirement:

The facility must prevent pressure ulcers and effectively treat those that are present.

Intent:

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.

Preparation:

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.

Reminder about restorative

2008-07-17T15:09:00.000-07:00

If a resident is receiving two different forms of restorative nursing at least 6 days a week, they will RUG into RLA or RLB (depending on the ADL score). This can mean up to an extra $75 per day, which amounts to roughly an additional 2K/month - 24K/year.

Profiting from Private Duty

2008-07-08T14:31:00.000-07:00

At the beginning of this month, the state of Tennessee enacted a new law that shifted a large portion of Medicaid's long term care designated funds from nursing homes to in home private duty care services. This has obviously caused nursing home providers a great deal of worry, a' la "We're gonna lose all our patients!" The new law is actually a blessing in disguise to nursing homes because it gives us a perfectly valid reason to expand our product lines. Having a nursing home to provide home care services is a winner. The biggest issue in private duty nursing is human resources (recruiting and retaining nurses and techs, credentialing, staffing, etc.). Nursing homes have been dealing with these same issues for years and have the tools to address them (although many choose not to use for whatever reason). Since most nursing homes have an existing CNA training program in place, training additional caregivers would not become a problem. Staff could (not should) be rotated in between private duty and nursing home divisions, and developing a PRN pool would be a little bit easier. Additionally, community relations could be maintained and/or improved, particularly in rural areas, and continuity of care could be taken to new heights.

New training slides

2008-06-30T14:57:00.000-07:00

This month's free staff development powerpoint shows are now available at www.parragonhealth.com/slides.htm. The topic is survey preparation.

The PHI books

2008-06-27T06:05:00.000-07:00

Although this has been posted here before, I have had some requests to repost the links to two manuals available for free from the Paraprofessional Health Institute. They are:

Coaching Supervision

Peer Mentoring

4 Thoughts

2008-06-27T05:58:00.000-07:00

I was in a most excellent training session with Dianne Harris earlier this week. Here are four little tidbits I picked up on:
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.

Thoughts on Nursing Home Reimbursement

2008-06-16T06:48:00.000-07:00

There is no business case for quality in long term care. There certainly is in the hospital industry, where compliance with evidence based practice practices was shown in a Premier demonstration pilot to save 11K per CABG patient. The reason that nursing homes can't afford quality is the current reimbursement system. Under RUGs, we are financially rewarded for keeping residents sick and maintaining utilization of resources as high as possible. While this is good for the bottom line, it is no good to residents. Perhaps we could look at going back to capitation, a system in which a facility is paid X amount of dollars per month per resident, with the dollar amount being determined by the average cost of care for nursing homes in that region. While this may not be the best system for skilled residents, it is certainly feasible for residents receiving an ICF level of care. Nursing homes would then have an incentive to maintain quality standards, because poor resident outcomes would result in nursing homes having to absorb that cost (ie, there would not be additional payments for in-house acquired pressure ulcers or other preventable complications). Hospitals have a list of no-pay diagnoses, inpatient acquired complications that they are not allowed to bill for. Third party payers should demand the highest quality of care from nursing homes, just as they do from every other provider type.