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Nurse LeadershipPrep Course for CDONACindy Fronning, RN-BC, CDONA, FACDONA, IP-BC, AS-BC, RAC-CT
Director of Education
Master Trainer
NADONA
© 2019 National Association of Directors of Nursing Administration in Long Term Care, Inc. (NADONA LTC).
All rights reserved.
Lesson Two - Clinical Systems
© 2019 NADONA LTC
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Objectives
The Participant will be able to
Identify 3 resources/ systems needed to effectively validate the current clinical practices of care
Identify the system and system and processes needed to insure an appropriate admission and discharge
List the 2 types of theories on Aging
Name the 7 components of the Infection Prevention & Control plan
Define the components needed in a Base Line Careplan
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Facility Assessment
Your facility must conduct and document an assessment to determine what resources are necessary to care for its residents competently during day to day operations and emergencies.
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Facility Resources
Physical Structure
Equipment-focus on medical and if you have it and how is it maintained
Services- Physical therapy, pharmacy and specific therapy based on your population
Nursing personnel – validate education and or training and any competencies related to resident care
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Nursing Structure, Process and
Outcome
Focus on your structure
1. Assessment
2. Comprehensive Plans of Care
3. Revision of Care Plan
4. Services meet Current Clinical Standards of Practice
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A Shift to an Effective Report
Regulations state that a facility must include effective communication as mandatory training for direct care staff – implemented by November 28 2019
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Feedback, Data Systems and Monitoring
System in place to monitor care and service
System designed to incorporate feedback from caregivers, residents, family and staff as appropriate
Care processes and outcomes are monitored using performance indicators
Adverse events are tracked, monitored and investigated- injury of unknown origin, investigating abuse and neglect
Person centered care plan interventions are updated, implemented and communicated to staff, resident and representative
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System - Admission
Clarify your role as the Director of Nursing in the admission process are you part of the decision process
Implement a nursing capabilities list with validation of competence to deliver care and services based on current clinical standards of practice.
Clarify admission hours 24/7
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Admission Basics
Physical examination within 5 days
Admitting diagnosis with prognosis
Chest X-Ray or negative PPD in prior 12 months
PASAAR
Advanced Directives
Resident Rights in Room Placement
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System for Discharge and Transfer
System in place to identify person centered plan of care
to treat primary diagnosis and co-morbidities
Discharge planning begins upon admission –
communicate goals, potential length of stay and clarify support needed in discharge process
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Policies and Procedures
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Developing and Implementing Written P&Ps
A policy defines and provides rationale and evidence for a required practice (which includes guidance on how to implement the practice.)
A policy needs to state what the practice is and what it is based on
A policy needs a purpose that provides background that explains why the practice is needed
A procedure delineates the steps or actions needed for performing the practice
Key terms should be defined within the procedure© 2019 NADONA LTC
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Developing and Implementing Written P&Ps cont.
The P&P identifies who is responsible for following
this policy and procedure.
The steps should identify when the practice
should be performed
It should also provide any other related additional information regarding the practice
It should include the supplies and equipment
needed and supply monitoring
All resources used to create the document
should be referenced © 2019 NADONA LTC
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Policy & Procedure Implementation
cont.Feedback
To Leadership & staff
Highlights the importance of IPC activities
Keeps staff informed of P&P
Relayed in various manners
Summarized for the whole facility
By unit, shift or even by physician
Individual info shared on a 1:1 basis ( or at when infraction of P&P occurred.
Annual review of all policies and procedures© 2019 NADONA LTC
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Audits
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Nursing Audits
A nursing audit is the systematic and critical examination
of patient records, nursing reports, and other documented evidence in order to evaluate and monitor the quality of
care
Auditing helps to identify discrepancies between what is
done and what should be done
Purposes of a nursing audit include evaluation of nursing
care, to ensure that care is up to a set standard,
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Types of Internal Audits Process audit (PEOPLE)
Evaluates whether an intervention was performed in compliance with an accepted standard of care(
Accepted standards for providing nursing care can be documented in policy and procedure manuals, nursing protocols, and/or nursing care plans
Examples
Medical Record Documentation
Medication Administration
Handwashing
Use of PPE
Linen handling
Structure Audit
Assesses those factors that provide a safe and effective environment in which to provide care
Examples:
evaluating staffing ratios,
assessing equipment safety, and
documenting emergency preparedness planning© 2019 NADONA LTC
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Audits cont.Outcome Audit
Evaluates the outcomes of an intervention; the assumption is
that achieving the desired outcome will result in high quality patient care(3,7)
Measuring outcomes is considered by many experts to be the best method for assessing quality of care
Examples of outcome audits:
rates of patient falls,
prevalence of pressure ulcers,
rates of healthcare-associated infection (HAI), and
patient satisfaction scores© 2019 NADONA LTC
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External Audits
Goal of Medical Review
To determine the following:
The services are reasonable and necessary
Delivered in the appropriate setting
Delivered and coded correctly
Appropriately documented
Meets all requirements for Medicare coverage.
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MEDICAL REVIEW
Types of Reviews
Onsite Reviews
Off site Reviews
Reasons for review
Demand Bills (FI) VBP
Lower 18 RUG category (FI) QRP
Random (FI) Case Mix (State)
Focused Review (FI) Compliance (FI/OIG)
Other Payers
CERT (CMS)
RAC
Perm
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Infection Control
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Updated F-Tags associated with Infection Control
• F880: Infection Control
• F881: Infection Control & Prevention Program (ASP)
• F882: Infection Preventionist
• F883: Influenza and Pneumococcal Immunizations
• F690: Urinary Incontinence (UTI’s)
• F757: Unnecessary Drugs
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IP Program Elements
A system for preventing, identifying, reporting, investigating, and
controlling infections and communicable diseases that:
Covers all residents, staff, volunteers, visitors, and other
individuals providing services under a contractual arrangement;
Is based on the individual facility assessment;
Follows accepted national standards;
Written standards, policies and procedures in accordance with
§483.80(a)(2);
A system for recording incidents identified under the
IPCP and corrective actions taken by the facility
Personnel must handle, store, process and transport
linens so as to prevent the spread of infection. © 2019 NADONA LTC
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IP Elements cont.
An annual review of it’s IPCP and update their program as
necessary
An antibiotic stewardship program (ASP) (F881)
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Infection Prevention and Control Program
Policies & Procedures Must include, but are not limited to:
A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;
When and to whom possible incidents of communicable disease or infections should be reported;
Standard and transmission-based precautions to be followed to prevent spread of infections;
When and how isolation should be used for a resident; including but not limited to:
The type and duration of the isolation, depending upon the infectious agent or organism involved,
A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
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Policies and Procedures cont.
The circumstances under which the facility must prohibit
employees with a communicable disease or infected skin
lesions from direct contact with residents or their food, if
direct contact will transmit the disease;
The hand hygiene procedures to be followed by staff
involved in direct resident contact
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Skills that an IP requires
Must have the ability to be a
Leader
Critical Thinker & Data Collector / Interpreter
Communicator
Educator
Collaborator
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Infection Prevention Program
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Antibiotic Stewardship
Program Linen
Infection Preventionist
11/28/19
Annual review
& UpdateA system for preventing, identifying, reporting,
investigating, and controlling infections and communicable diseases
Written standards,
policies and procedures
RecordingIncidents/
Actions
Infection Control vs Antibiotic Stewardship
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Antibiotic Stewardship Program (ASP)
A system for preventing, identifying, reporting, investigating, and controlling
infections and communicable diseases.
Uses many of the forms and process identified within the ICP
Written standards, policies and procedures
The ASP policies and procedures are a part of the ICP standards and Policies
Recording Incidents/ Actions The ASP forms and strategies are a part of the ICP
Linen This is a part of the Antibiotic program as well. Insuring that the residents and
staff are free from infections through the linen
Annual review & Update
Both the ICP and ASP need to be reviewed annually which since the ASP
is a part of the ICP plan it is all done at one time.
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Surveillance
Purpose :
Identify infections
Monitor that the IPC practices are being followed
Prevent the spread of infections/pathogens within the facility
Outcomes of the IPC program data help to:
Identify trends (infections/pathogens)
Detect outbreaks
Determine level of compliance with P&Ps
Recognize opportunities to improve IPC practice performance
Track progress towards identified priorities on the risk assessment and use in developing new priorities
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Types of Measures
Process (Performance) Measures:
Identify specific practices for monitoring staff compliance
Performed through
Practice audits
Direct observation
Review of documentation
Outcome Measures
Specific infection events (infection/pathogens)
MDROs
Helps identify outbreaks© 2019 NADONA LTC
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Process Surveillance
Using the facilities P&Ps
Choose the IPC practices that could pose the greatest risk to the residents
and staff if not followed:
Use of PPE
Look at:
appropriate PPE for the type of transmission isolation
Appropriate donning and removal of PPE
Disposal of PPE
Handwashing at appropriate times
Identify if barriers to compliance
Use data to provide 1-1 education at time of observance and additional
training to other staff
Considered practice improvement
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Outcome Surveillance
Facility Wide:
Examples:
Resident has a fever
New antibiotic start
Redden skin (wound)
Investigate every opportunity for infection
Fill out the forms and track the proposed infection
Targeted
New diarrhea
Vomiting
URI
Abnormal Lab values© 2019 NADONA LTC
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Investigations
Investigating an Infection
Determine type of
organism/pathogen
Location/site of infection
Cause or contributing factors
Onset of symptoms
Symptoms
Treatment© 2019 NADONA LTC
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Reporting
What infections do you need to report:
CMS identifies required nationally reportable diseases each year.
Certain States have lists of reportable
disease.
NSHN receive voluntary reporting of infections
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Vaccinations
All residents must be offered the Influenza vaccine and the pneumococcal vaccines on admission and the Influenza vaccine yearly
Residents/ family must be educated as to the risks and benefits of the vaccine prior to the administration of the vaccine
Reasons why a vaccine might not be givenAlready received it
Refuses it
Medical Contraindications
Fever / Impaired Immune system
Unable to obtain vaccine due to a declared shortage© 2019 NADONA LTC
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Types of Outbreaks Cluster/Outbreak
the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season
Epidemic
widespread occurrence of an infectious disease in a community at a particular time. "a flu epidemic”
Endemic
The usual incidence of a given disease within a geographic area during a specific time period
Pandemic
An epidemic (a sudden outbreak) of infectious disease that becomes very widespread and affects a whole region, a continent, or the world due to a susceptible population ...© 2019 NADONA LTC
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Pharmacy
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Pharmacy Monthly Regime Review Reviews all resident’s medical records for :
Medication reconciliation
Review of all medications residents are using
To identify and potentially prevent clinically significant medication
adverse events
Adverse event would require a physician be notified & orders to be
implemented by midnight of the next calendar day (at the latest)
Actual Harm Tag F 756
Eliquis 5 mg bid AF
Dental surgery ordered held x 24 hour, deleted from
EHR
Next visit by consultant pharmacist no irregularities
Embolic CVA hospice / dies
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F 756 – DRUG REGIMEN REVIEW National Trends:
Failure to identify irregularity
PRN psychotropic > 14 days
No justification/duration in the record
Failure to respond to recommendations timely
“During an interview on 4-14-18 at 8:34 AM, the Administrator stated that the
DON was unable to locate any pharmacy recommendations for prior
months. S/he said that reports had been going to the DON who has just been
setting them aside.”
Failure to maintain recommendations in the record
Policy 9.1 Medication Regimen Review (MRR), Procedure 12. revealed that
the Facility should maintain readily available copies of MRRs on file in Facility
as part of the resident’s permanent health record.
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F 756 Cont. Pharmacist also reviews for:
Lab Reports
Antipsychotics
Antibiotics
Complete order
Symptoms
Submits a report every month to the DON of all irregularities and provides comments and suggestions for physicians.
This report is given to the DON, Medical Director or attending physician
Usually the DON receives it documents that she has read it with Initials and dates
Then forwards it to the attendings and the Medical Director.
A quarterly report is prepared by the Pharmacist for the QAPI meeting
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F 758 – PSYCHOTROPIC DRUGS
National Themes:
Failure to document indication
Failure to attempt GDR (All 4 classes)
Failure to monitor individualized target
behavior
Failure to address via comprehensive care plan
Failure to attempt non-pharm intervention
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Med Diversion
Pro Active Med Diversion Interventions
Counting of Narcotics between shifts
Checking documentation
Permanently affixed storage compartments that are Double Locked for Scheduled II narcotics
Monitoring of Med Carts and Med Rooms
Any irregularities are forwarded to DON© 2019 NADONA LTC
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DEFINITION: DRUG IRREGULARITY
“ … use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or
interferes with achieving the intended outcomes of pharmaceutical services.
An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate
monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy.”
- Guidance to Surveyors: F 756
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DEFINITION: PHARMACEUTICAL SERVICES
The process (including documentation, as applicable) of receiving and interpreting prescriber’s orders; acquiring, receiving, storing, controlling, reconciling, compounding
(e.g., intravenous antibiotics), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals (e.g., povidone iodine, hydrogen peroxide);
The provision of medication-related information to health care professionals and residents;
The process of identifying, evaluating and addressing medication-related issues including the prevention and reporting of medication errors; and
The provision, monitoring and/or the use of medication-related devices…
- Guidance to Surveyors: F 755
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F 881: INFECTION PREVENTION / CONTROLABT STEWARDSHIP
Up to 75% of antibiotics prescribed in nursing homes are
prescribed incorrectly
The most common prescribing problems in nursing homes
are:
Using an antibiotic when not needed
Choosing the wrong antibiotic
Using the correct antibiotic but for the wrong dose or duration- Center for Disease Control and Prevention
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Skin Integrity
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F686 Skin Integrity
The intent of this requirement is that the resident does not
develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and
services consistent with professional standards of practice to:
Promote the prevention of pressure ulcer/injury development;
Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and
Prevent development of additional pressure ulcer/injury.
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DON’s Responsibility
To provide training in best clinical practice to avoid a
decline in skin integrity
To investigate every skin issue
To identify risks and interventions to prevent further skin integrity decline as well as to prevent it from happening
to others
To mentor and monitor staff to insure policies and
procedures are being followed
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EMR/ Documentation
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Electronic Media Electronic Media
Such as EMR
Phones
Face Book
Snap Chat
Policy should include:
How & where the media can be accessed
Every employee must provide the facility with a hard copy record of all passwords used on facility equipment
All information sent by employee via an electronic network must
comply with facility policy© 2019 NADONA LTC
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Documentation
If it isn't documented it wasn’t done
The Do's That Make Charting Easier
Check that you have the correct chart before you begin writing.
Make sure your documentation reflects the nursing process and your professional capabilities.
Write legibly / type using spell check!
If writing use a permanent black ink pen...other colors
do not Xerox well.
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Documentation cont.
Chart completely, concisely and accurately ("Tell it like it is.")
Write clear sentences that get right to the point
Use simple, precise wordsDon't be afraid to use the word "I"
Examples:
Wrong Way: Communication with patient's family begun today to specify the manner in which his condition is progressing and
suggest a probable consequence of that progression.
Right Way: I contacted Mr. Brown’s wife at 14:15 hours. I explained that his cardiac status was worsening and that he was prepared
for a cardiac catherization procedure scheduled for 1600 hours.
Chart the time you gave a medication, the route given and the client’s response.
Chart precautions or preventative measures used, such as heel pads.© 2019 NADONA LTC
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Charting Do’s cont.
Include the following information when documenting nursing procedures:
What procedure was performedWhen it was performedWho performed itHow it was performedHow well the client tolerated it
Adverse reactions to the procedure, if any
Record each phone call to or from a physician, including the exact time, message, and response.
For more do’s and don'ts for training see handout in lesson 2
handouts
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Care Plans
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Care Plans
Baseline Care Plan Within 48 hours of admission
Comprehensive care plan within 21 days of admission or within 7 days of the comprehensive MDS completion (CAAs signed off).
Resident Focused
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Must :
Be developed within 48 hours of a resident’s admission
Include the minimum healthcare information necessary to properly care for a resident
Must include at a minimum:
Initial goals based on admission orders
Physician Orders
Dietary orders
Therapy orders
Social Services
PASARR recommendations
Base Line Care Plan 58
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Base Line Care Plan Check List
Reason for Admission
Advanced Directives
Discharge Plan
Special Conditions
(PASARR 2)
Emergency Preparedness
Dressing Bathing Grooming
Mobility
Toileting
Skin
Communication
Fall Prevention
Adjustment / Behaviors/ Mood
Cognition
Comfort / Pain
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The Following Categories need to be addressed according to the individual resident’s needs and orders :
Cultural Preferences
Restraints and Alarms
Special Conditions (Be sure all the appropriate interventions are selected as they were written to meet the regulations)
Dialysis
DM (Diabetes)
Hospice
Pneumonia
Respiratory
Other (Mixture of conditions and interventions)
Vent/Trach/Respirator
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Base Line Care Plan cont.
Summary of Medications
Medications & Treatments
Dietary Instructions
Diet/Eating
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Must be provided with a summary of the baseline care
plan that includes at a minimum:
The Initial Goals of the resident
A summary of the resident’s medications and dietary instructions
Any services and treatments to be administered by the facility personnel
If Base Line Care is updated it needs to be shared with them
Need to sign that they have reviewed the care plan
Resident/Resident’s Representative62
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Facility must develop and implement a
comprehensive person- centered care plan for each resident;
Consistent with the resident rights
Include measurable objectives and timeframes
To meet a resident’s medical, nursing and
mental and psychosocial needs that are identified in the comprehensive assessment
(MDS) and including trauma-informed care
The Comprehensive Care Plan 63
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Developed within 7 days of signing off CAAs
Prepared by the Interdisciplinary team /attending Care Conference
Attending Physician
A registered nurse with responsibility for the resident
A nurse aide with responsibility for the resident
A member from dietary
A member of the activity department
Social services personnel
The resident if practicable
The resident’s representative if possible
Need to sign that they have reviewed the care plan
Comprehensive Care plan64
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The resident’s goals for admission and desired
outcomes
The resident’s preferences and potential DC
Discharge plan
Together with the Resident & Resident’s
Representative Determine65
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Updated after each OBRA MDS
assessment
Updated as resident’s plan or services
changes
Must meet professional standards of quality
Be provided by qualified personnel
Be culturally competent and trauma -informed
Comprehensive Care Plan66
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Aging
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Theories of Aging
Programmed Theories – support that the human body is designed to age and there is a certain biological timeline that our bodies follow. aging hold that aging is a directed
process, a normal process just as puberty is a normal developmental process.
Programmed Longevity: Aging is caused by certain genes switching on and off over time. There are specific genes which help a person live longer.
Endocrine Theory: Changes in hormones control aging.
Immunological Theory: The immune system is programmed to decline over time, leaving people more susceptible to diseases. © 2019 NADONA LTC
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Theories of Aging cont.
Error Theories – support that aging is caused by environmental damage to
our body's systems, which accumulates over time. Aging is not something which is programmed to occur, but rather aging is due to a series of
"accidents."
Wear and Tear: Cells and tissues simply wear out.
Rates of Living: The faster an organism uses oxygen, the shorter it lives.
Cross-Linking: Cross-linked proteins accumulate and slow down body
processes. Excess sugars in the bloodstream can cause protein
molecules to literally stick together.
Free Radicals: Free radicals cause damage to cells that eventually
impairs function. Unstable oxygen molecules which can damage cells.
Somatic DNA Damage: Genetic mutations cause cells to malfunction. For unknown reasons, the systems in the body to repair DNA seem to
become less effective in older people. © 2019 NADONA LTC
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Resources
https://www.ebscohost.com/assets-sample-content/NRC_Plus__Nursing_Audits_an_Overview___EBCS.pdf
https://www.verywellhealth.com/why-we-age-theories-and-effects-of-aging-2223922?utm_term=theories+of+aging&utm_content=p1-main-2-
title&utm_medium=sem&utm_source=msn_s&utm_campaign=adid-e7f20dd0-9181-496f-b6ef-303a32bfad9a-0-ab_mse_ocode-29655&ad=semD&an=msn_s&am=exact&q=theories+of+aging&o=29655&q
src=999&l=sem&askid=e7f20dd0-9181-496f-b6ef-303a32bfad9a-0-ab_mse
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Questions???71
