Monitoring Weight Variance

Monitoring weight variance, either loss or gain, is an important factor in keeping Long Term Care (LTC) residents as healthy as possible. Accurate weight measurement is critical to a nutritional assessment. The information is necessary to calculate fluid needs as well as macronutrient amounts and is often used to calculate medication dosages. A patient’s weight  measures health and nutritional status over time.

The resident should be weighed as soon as possible after admission to obtain a base weight and provide the dietician with the information prior to the nutritional assessment. The resident should be weighed weekly for the next three weeks and monthly thereafter (follow the facility protocol).

The physician may request a daily weight for some diagnosis (like congestive heart failure) or if the resident is receiving diuretics or is on hyperalimentation. The resident should be weighed at the same time and if possible, by the same person. Having the same caregiver assigned to the weighing process will assure procedural consistency. The resident should be weighed without shoes and with as little clothing as possible.

Scales need to be calibrated monthly and a log maintained of the measurements. Ambulatory residents may use a platform scale. The resident should stand on the center of the platform without hanging on to anything. If the resident wears an adaptive device or a prosthesis, it should be documented if the weight was obtained with or without the device and should be consistent every month.

Chair scales should be used for non ambulatory residents. The wheelchair is weighed separately and then the resident is weighed in the wheelchair. The resident should be seated in the center of the chair and the wheelchair centered on scale for accurate measurement. Subtract the chair weight from the overall  weight to obtain the resident’s weight and be sure the math is accurate.  Sling scales and bed scales may be used but follow the manufacturer's’ directions for safety and make sure staff receive appropriate training on their use.

There are set parameters for reporting weight gain or loss. These are reported to the physician and documented in the resident’s record.

5% gain or loss in one month

7.5% gain or loss in three months

10% gain or loss in six months

The dietician should also be informed and physician’s orders must be in place to correct any problems. Federal regulation 325 refers to a patient's nutrition, “Receives a therapeutic diet when their is a nutritional problem”.

I love acronyms as they help me remember important facts. The Texas Department of Aging and Disability (DADS) use the following to list the risk factors associated with weight loss.

M- medication

E-emotional problems

A-anorexia

L-late life paranoia

S-swallowing disorders

O-oral problems

N-nosocomial infections

W-wandering

H-hyperthyroidism

E-enteric problems

E-eating problems

L-low salt and low cholesterol diets

S-social problems.

Nurses need to recognise these factors and identify the residents who are at risk. Should a significant weight loss occur, the resident must be reweighed within 72 hours. If the weight loss continues, the physician, family and dietician must be notified and an intervention must be put in place immediately.

Interventions may include:

Reassess the effects of medication.

3 day calorie count, document food intake at each meal for 3 days.

Manage underlying conditions.

Facilitate increased food consumption by providing snacks, nutritional supplements, finger foods and provide socialization by inviting family members to sit with resident at meal times.

Staff may assist with feeding and should offer praise for improved endeavours.

It is very important to document dates and notifications concerning nutrition in the medical record. Results of interventions and a weekly weight needs to be documented until the patient's weight stabilizes.

Many times there is an apparent reason for loss or gain. If the resident is on a diuretic or has had a recent paracentesis, weight loss is the expected outcome. Awareness of the resident’s appetite and food dislikes is important. Certain religious beliefs may interfere with dietary choices (A social service assessment should have picked up on this and should be in the care plan). Cultural choices and dislike of certain foods may also play a role in weight loss. Depression is the most identified cause of weight loss and must be treated. As terminal illness advances and end of life approaches, loss of appetite and weight loss occurs naturally.

Weight gain is expected when a resident recovers from surgery or an infection. Nutritional supplements and mineral and vitamin therapy also help in increasing appetite and gaining weight. In cultural and religious areas, getting family involved in bringing an occasional appropriate meal from home can be helpful.

As always be sure to careplan problems, changes and interventions.

Diabetic Mangagement

Diabetes can be a lifelong condition that affects the body’s ability to use the energy contained in food. There are 3 types of diabetes, Type One, Type Two and Gestational.

The common factor involved in all three types is that the Insulin required to utilize glucose is either inadequate or unavailable. The hormone Insulin is required to enable the body’s cells to take in and utilize glucose. Without this hormone, high levels of glucose can accumulate in the blood stream, resulting in damage to the tiny vessels in the eyes, heart, kidneys and nervous system.

I will give a brief description of the other two types of diabetes. Type Two is, by far the most common, especially in patients in Long Term Care (LTC) facilities

In Type One diabetes, the hormone Insulin, secreted by the pancreas is not available. Studies show there may be two reasons for this: (1) the body may produce antibodies that damage the pancreas and therefore it is unable to  produce insulin or (2) there may be a genetic disposition that result in faulty beta cells that are unable to make Insulin.

Gestational diabetes is triggered by pregnancy and usually abates with childbirth. It can, however, put the mother at risk for developing Type Two diabetes later in life.

Type Two diabetes was previously called adult onset diabetes. However, it is now occurring in much younger people. If left untreated, it can eventually cause heart disease, stroke,kidney disease, blindness and nerve damage (neuropathy).

There is no cure for diabetes but it can be controlled with good nutrition, weight management and exercise.

Type Two diabetes occurs when the pancreas does not produce enough insulin or the insulin cannot be used appropriately by the body’s cells (insulin resistance) or a combination of both.

Statistics from the American Diabetic Association (ADA) indicate that 25% of residents living in LTC facilities have Type Two diabetes. Of this number, 80% of patients have cardiovascular disease, 56% have hypertension and 70% have 2 or more other chronic conditions, such as, chronic kidney disease (CKD), coronary artery disease (CAD) and stroke.

Studies in Great Britain have shown that by keeping the Hemoglobin AIc levels of blood below 7, preferably at 6.5, the risk of these diseases occurring, are drastically reduced. When hemoglobin joins with glucose in the blood it becomes “glycated”. By measuring the “glycated” blood (HbA1c) clinicians can get an overall picture of the average blood glucose concentration over a 3 month period. In people without diabetes the level is 6 or less. For good control in diabetics it should be maintained at 7 or below. This test is taken a few times a year and can be used to monitor the effects of diet, exercise or medication.

In LTC facilities, the residents with Type Two diabetes, will decline in health if not treated. Dehydration, depression, confusion, eye problems, foot ulcers, neuropathy, and recurrent infections, slow healing wounds and decline in performing the activities of daily living (ADL) will be present if the diabetes is not controlled. This control is individualized according to the patient’s condition.

Many factors associated with aging can affect glucose metabolism in older adults. Selecting the correct medication based on these factors can be difficult. Some of these factors include, increased adipose tissue and decreased muscle mass. Alteration in food intake and ability to exercise. Insulin resistance in the cells, co-morbid health conditions and drug interactions. Some psychosocial factors include stress and depression.  As most of LTC residents are admitted with a history of type two diabetes of many years duration, the medical staff  need to be aware of the disease processes already present.

As always, the resident and family need to be  involved in discussing how aggressive treatment (diet, exercise, blood testing and medication) will be. The ADA has very good information on all issues pertaining to appropriate treatment. The hands-on care staff must follow the physician’s orders and be aware of the resident’s plan of care.

Blood sugar control is the key to good diabetes management. Preventing episodes of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) is of the utmost importance. Be aware of the parameters provided by the laboratory and follow the facility guidelines for treatment.

Hypoglycemia occurs when the blood glucose levels are at 70 mg/dL or less. Signs or symptoms  include:

Weakness or tiredness

Hunger

Dizziness or feeling shaky

Sweaty

Rapid pulse

Blurred vision

Unresponsiveness

The main reasons for hypoglycemic episodes are:

skipping a meal or consuming too few carbohydrates,

increased physical activity and some medications. A long time interval between taking insulin diabetes medications and eating can also cause hypoglycemia.

The best way to treat this illness is to be prepared. Follow the facility guidelines and know where the necessary equipment is stored. Nurses need to be aware of residents with dementia who also have diabetes. These residents are unable to recognize or discuss symptoms and must be monitored carefully. Parameters must always be available for administering insulin and other diabetes related medications. Physician and family must be notified of any episodes that may occur and these must be included in the nurses’ documentation in the clinical record.

Once again, I will say how important is good communication. “How do you feel this morning” can provide a wealth of information. The resident may not know why she is shaky, sweaty or thirsty, but we do and if she is a diabetic, we should test her blood sugar levels.

Hyperglycemia occurs when there is a high level of glucose in the blood. Some laboratories indicate a fasting blood sugar greater than 130 mg/dL as hyperglycemic.

S/Ss usually include increased thirst, headache,frequent urination, blurred vision, fatigue and weight loss.

May occur when an insulin dose or prescribed diabetes medication is omitted, consumption of high carbohydrate meals, an infection or illness and some medications (steroids) may produce hyperglycemia.

Blood sugar monitoring is ordered by the physician and should be performed exactly as prescribed and the results documented in the diabetic flow sheet immediately after testing.

Accu-chek Meters. There are many different types of meters in use for testing the levels of glucose in blood. The nurse must become familiar with the type used in the facility and must follow the policy for care, infection control and privacy during testing. An abnormal reading, high or low, should be followed by a nursing intervention.

Always refer to the physician’s orders and document.

It is very important that there is a limited time lapse between testing and administering the prescribed insulin or medication and between the medication and food intake. By being consistent and observant, our residents are kept more safe and our workload is made lighter by preventing complications.

Psychotropic Drug Reduction

More than 50% of all Long Term Care (LTC) residents have some form of dementia This affliction in mental ability is severe enough to interfere with daily life.  Memory loss is one result of dementia. Residents may also have difficulty in completing familiar tasks and may have  problems with forming words while speaking or writing and may become easily confused. They may often misplace items and have lost the cognitive ability to retrace their steps. Residents with dementia  can also  display some untoward behaviors or psychological symptoms.  These behaviors may be wandering, hallucinations, aggressiveness and  difficulty with sleeping or eating, with various degrees of severity based on the underlying cause of the dementia and the progress of the disease.

Caring for these residents can pose a significant challenge to the direct  care staff. Staff should always remember that the resident is not being deliberately difficult. His or her sense of reality may be different from the staff’s, but it is still very real to the patient. Caregivers should learn not to take problem behaviors personally and do their best to keep their sense of humour and understanding.

Caring for residents with dementia by the use of unnecessary antipsychotic medication pose a big concern. Studies show that over 25% of LTC residents receive psychotropic medication. In 2012 Centers for Medicare and Medicaid (CMS) introduced explicit regulatory requirements to curtail the use of unnecessary psychotropic medications and improve behavior management in LTC facilities. The initiative expected a 15% reduction nationwide by the end of that year. Reports vary on the response but there is definitely a concerted  effort by LTC facilities to use a non-pharmacological approach to treating behaviors. The initiative is ongoing and by the end of this year (2015), CMS expects an  overall total reduction of 25%.

Without a doubt, the state public health surveyors will be paying close attentions to LTC dose reductions  and documentation when they visit a facility. The surveyors will also scrutinize F-tags 309 and 329 to see if the facility is in compliance with them. Nurses should really understand these F-tags and their interpretive guidelines. As nurses, the administering of the proper and necessary drugs to insure the highest practicable level of physical and mental well being of our patients should be the greatest priority.

Prior to a resident being prescribed an antipsychotic medication, four aspects must be clearly identified:

1. An appropriate indication for use.
2. A specific and documented therapeutic goal.
3. Ongoing monitoring of the resident for effectiveness and presence   of any adverse reactions from the medication.
4. The prescribed medication should be at the lowest effective dose and for the shortest duration needed.

Soon after the drug has been prescribed, the patient’s record must reflect a continuing and concerted effort to decrease the dose and discontinue the drug. Psychotropic drugs are targeted for gradual dose reduction (GDR) because consensus has been reached that they have been overused  and that their risk is higher than any potential benefits with continuous use.

Documentation should be very thorough in describing the adverse behaviors and the nonpharmacological approaches used to curtail the behaviors. If the behavioral symptoms represent a change or worsening, a medical workup should be performed  to rule out underlying physical or medical causes of the behaviors. Causes to be considered can be either physical  (gastrointestinal distress, constipation, pain or respiratory difficulties) or medical (infection, dehydration, delirium, hypoglycemia or hypothyroidism). If other causes are identified (environmental), was treatment initiated timely?

Psychotropic medications should not  be administered without a signed consent by the patient or the person designated as the patient's power of attorney (POA). A verbal consent will cover an emergency situation but should be signed as soon as possible. (Follow your facility’s protocol). 

The Black Box warning issued by the Food and Drug Administration in 2004 states ”that there is an increased mortality in elderly patients with dementia related psychosis”. It is important that the nurse informs the POA or the patient's family of this warning and should document in the medical record that this information was provided and the response from the family or POA that was received. The FDA also has a list of approved diagnosis for prescribing antipsychotic medications. When prescribed without the FDA approved diagnosis, it is considered “off label use”. Appropriate monitoring of blood levels or systemic response needs to be evaluated at frequent intervals.

It is important that the direct care staff are educated on dementia and the behavioral techniques available to manage the behavior problems. A smile and reassuring touch can go a long way to convey your message and show your understanding. Try and figure out what caused the behavior, if the resident is wandering, where does he/she want to go? Are they hungry, thirsty or need to go to the toilet? These needs should be met as quickly as possible.

A calm and soothing environment should be created to reduce noise levels and confusion.  Exercise is a very important factor in mental health. Short walks should be utilized if the patient is physically able or if not, looking out the window to admire the scenery can be helpful. Even looking at the different colors and makes of cars in the parking lot may spark an interest for some residents, Chair or seated exercises  with a background of soothing music may be beneficial. Simple activities such as folding towels, watering plants or winding yarn can provide an alternative to the behavior. Reading simple poetry or stories or discussing appropriate current events to small groups and asking questions during the discussions may be of interest to some. Reminiscing can be very helpful as residents with dementia seem to have a better grasp of the distant past rather than the immediate present. Discuss previous occupations and hobbies. Pets can provide some positive non verbal communication and the resident may remember owning a pet previously.

Above all, the need for human interaction is the greatest one the resident has. Even the shortest visit can increase their physical and social activity, and provide sensory stimulation.

Always follow the facility policy and document behaviors, interventions and responses. Documentation should include date, time, location, specific behavior, triggering factors and how it interferes with care. Also document the intervention and response, and always include in the care plan. If a drug is administered document the resident’s response to it.

I have found some very current and informative presentations from LeadingAge Illinois (formerly Life Services Network) https://www.lsni.org/. I cannot stress enough how necessary it is for caregivers to keep up with current information.

End of Life Care

Over the many years of my nursing career, I have learned to acknowledge and appreciate change and I now look at  it as an improvement on the past. I firmly believe that a mind set of ongoing learning is the best quality of all caregivers.

In the past, people were reluctant to talk about death, although we realize that death is the final stage of life. All nurses should read Dr. Eleanor

Kubler-Ross’ book on “Death and Dying”. I have been fortunate enough to attend some of her lectures on the subject and I have achieved  a much greater understanding and acceptance of death. So in this blog I will discuss End of Life (EOL) Matters.

POLST (Physicians Orders for Life Sustaining Treatment) is an approach to end of life planning. All of the critical elements of EOL care are covered in this form. Completion of this is the responsibility of the Primary Care Physician. (PCP) but usually it is the social worker that  introduce EOL information to the Long Term Care (LTC) resident and family as well as schedule an appointment with the PCP.  This meeting should be conducted between the resident, loved ones and the PCP.  It ensures that seriously ill or frail residents can choose the treatment they want, or do not want and that their wishes are documented and honored.

POLST has been adopted by all but eight States. It gives seriously ill residents more control over their end of life care, including cardio pulmonary resuscitation (CPR), medical treatment and extreme endeavors like ventilation and tube feedings. It must be signed by the resident and physician.

The POLST form is copied on pink paper to ensure the document stands out in a resident’s file. However, copies and faxes in any color paper is considered legal. The POLST form is also accepted by emergency medical response teams.

Advance Directives inform the physician the kind of care, the resident has chosen, should they be unable to make a medical decision for themselves.

An Advanced Directive can include one or all of the following:

Living Will

Durable Power of Attorney (POA) for health care

Do Not Resuscitate (DNR) orders.

A Living Will is a signed and witnessed legal document, describing the kind of medical treatment, or life sustaining measures the person wants if they become seriously or terminally ill.

A Durable POA for health care is a document stating who has been chosen to make health care decisions for the person, if they are unable to do so themselves. This is also a legal document.

A DNR order informs the medical team that the patient does not want to be resuscitated in case of a life terminating medical event. The DNR should be signed by the physician and should be an ongoing part of the monthly Physician’s Order Sheet (POS).

Though it is not required in all states, it may be prudent for the LTC to have in the resident’s file a form covering Health Insurance Portability and Accountability Act (HIPAA ).That way the physician and facility will know to whom they can release information about the resident. It is important that all residents in Long Term Care (LTC) facilities have some end of life determination in place. Should a crises occur, the nurse should know  immediately how to respond.  There can be legal consequences to inappropriate response to end of life care.

The positive factors for POLST are many. The dignity and desires of the  residents  are safeguarded. The residents have a voice on how they are treated in a medical crises. The residents can request or refuse certain medical treatments, such as   CPR and hospitalization by selecting Comfort Measures Only in a POLST assessment. They can also request  limited  interventions, or they can choose full treatment which includes all measures to sustain life. As end of life approaches for the resident, family members may have significantly different emotional responses. It is very beneficial that the choice has been verified by the resident.

Long Term Facilities  can also use Hospice as a resource to ensure that appropriate EOL care is provided. There must be a signed contract between the LTC facility and the Hospice provider that outlines the roles and responsibilities of each.  The resident must be in agreement to receive hospice care. The LTC nurse should notify the hospice of any changes in the resident’s condition. It is also necessary the hospice nurse participates in the care plan documentation.

Falls, Incidents and Accidents

A fall is described as  involuntarily coming to rest on a lower surface, or “an unintentional loss of balance, causing one to make unexpected contact with the ground or floor”.(Texas A&M University, October 2013).

Whether a resident has been observed stumbling and has been assisted to the floor or the fall is an un-witnessed event that leads to an injury, all falls have to be reported and investigated. This will determine what interventions must be put in place to keep the resident safe. With  un-witnessed falls, we should play it safe by doing neurological checks on the resident.

All other incidents and accidents, including bruising and skin tears must be reported, investigated and interventions put in place to prevent any re-occurrence.

Falls are unfortunately a frequent occurrence in Long Term Care (LTC) facilities. Falls have an extremely adverse reaction both physically and psychologically on the elderly. Many residents die as a result of a fall and those who survive may sustain injuries that can cause functional decline, decreased mobility or permanent disability. Falls can also result in pain and discomfort. Psychological impacts can include loss of confidence, becoming socially withdrawn and feel less independent.  All or any of the above factors can reduce the resident’s quality of life.

LTC facilities should have in place the following procedures:

Fall Policy: There should be a process in place for investigation and treatment.

Fall Prevention Program: Many facilities have discreet programs in place to identify residents at risk (a sign of a falling leaf that would indicate to staff a resident at risk of falling, safety signs, colored bracelets) etc.

A Fall Team that should convene monthly to discuss current falls,  the reasons residents fell, interventions and measure outcomes for success or failure. A fall log should be maintained listing fall occurrences, interventions and outcomes including date and time of fall and of notification of physician and family. All staff should follow the facility policy for reporting to the proper state agency.

Everyone on staff should understand why falls are a risk factor and should know the residents who are frequently fall or those at a high risk for falls. The key is to be always watching the residents, to monitor what they are doing and interact with them as often as possible. Awareness of the legal liability associated with falls and resultant injuries should be a high priority for caregivers.

Caregivers should identify prevention techniques and therefore we should always be on the look out for any changes in the resident. The nurses aid is the eyes, ears and hands of the care team and detecting change is one of the most important things she/he can do. Knowing the resident’s ability to move around, transfer, perform Activity of Daily Living (ADL), and identifying a decline can predict the risk of falling.

Based on frequent assessments, the direct care staff should know if the residents can recognize their safety needs, can remember and understand those needs. Residents should be reminded frequently to call for help and they should be reassured that the nursing staff are there to help.

When a fall occurs it must be investigated immediately and completely.

Care and safety of the resident is always first. Some of the factors that need to be considered are:

Describe the fall scene, what was the resident attempting to do?

Was the call light on and unanswered?

Was it within reach of the resident?.

When was the resident last seen, toileted or medicated for pain, etc.

Were adaptive devices involved?.

Recreating the scene with witnesses and team members may be beneficial. Monitoring that all previous interventions are in place is necessary.

Identify and review all intrinsic and extrinsic factors.

Muscle weakness, gait impairment and poor balance are the most common causes for falls. Age related risks including  poor eyesight, disease progression, memory loss and poor judgement are all causal factors. Hypoglycemia, hypo-tension and medications that affect the Central Nervous System, such as sedatives and anti- anxiety medications also need to be checked.  The resident should be monitored for 72 hours following any changes in the dosage of these drugs.

Environmental hazards, such as  wet floors, poor lighting, rugs or carpets that are not properly secured and clutter can all contribute to falls and injuries. Equipment, including walkers, wheelchairs and lifts all need to examined to ensure they are properly maintained. Residents who use powered wheelchairs should be assessed frequently by the physical therapy to insure ability and safety. The maintenance department should examine all equipment routinely to determine safety and repair needs.

Interventions must be related to the cause of the fall. The care team should discuss the best one to keep the resident safe and avoid re-occurrence. For residents with cognitive problems, behavior strategies to help avoid hazardous situations may be necessary. All interventions must be included in the care plan and staff must be aware of them. Most important, the intervention must be used, for it to work.

Exercise programs to improve balance, physical functioning and ambulation ability may be provided by Physical Therapy or Restorative Nursing.

Complaint Investigations

All residents’ complaints, no matter how trivial, should be investigated and documented. A log should be maintained containing information about complaints such as the nature of the complaint,date, time, persons involved, witnesses, interventions and outcomes. During the compliance survey process, a state or federal surveyor may request to see the complaint log for the previous year.

When investigating a complaint, the resident’s version of the incident should  be given as much credence as the staff member’s. Residents with numerous complaints may require social service intervention to help identify reasons for any discontent/dissatisfaction. Good communication is vital and problem solving should  be proactive  not reactive.

The Elder Justice Act is a preventative law that protects the elderly from  abuse, neglect and exploitation. It is part of the Patient Protection Affordable Care Act (PPACA) passed in 2010.  Elder abuse refers to actions or lack of actions that can harm or place in harm’s way any elderly person. Nursing home personnel should acknowledge that abuse could happen in their facility and they should always be on the alert for prevention, intervention and treatment of elder abuse.

The law mandates reporting requirements. Federal regulations require all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator of the facility. A hotline for reporting should be available 24/7 and an abuse coordinator is usually the administrator or a designee if the administrator is unavailable.

If serious bodily injury occurs, a report must be made to the state survey agency (such as the Department of Public Health) and the local law enforcement  agency within 2 hours.  When a staff member is involved, he/she is immediately  suspended and must leave the facility until the investigation is completed. Less serious issues are reported to the state agency within 1 day and a final report including investigation, findings and interventions are reported in 5 days. Mistreatment, neglect and all forms of abuse, including verbal, mental, sexual and physical, injuries of unknown origin,and misappropriation of resident’s property are all reportable offences.

To assist in the prevention of abuse, the facility should post a list of residents’ rights and should provide  mandatory training on Abuse prevention and reporting.  Appropriate staff screening and signs and symptoms of staff burnout  should be monitored.  Awareness of staff attitudes and actions regarding  abuse reporting is important. Staff members should feel they can report problems without fear of reprisals or retaliation.

Clinicians should also monitor problems of aggression between residents and appropriate interventions for separation should be put in place.

Outcomes of visitation should always be positive. On one occasion a resident complained to me she had overheard a visitor verbally abusive to the other resident in the room. When the visitor left, the resident cried for long periods. An investigation determined that she was correct. The daughter of a resident was attempting to get money from the resident. The daughter was forbidden to visit except with supervision. The resident was brought to the dayroom during visitation, where staff could observe for any negative interactions.

As I have stated earlier the physician and family members  should be notified timely and the necessary documentation should be completed.

Communication and Documentation

                   

Communication is an essential component of any caregiving relationship. Studies have  shown  that a lack of communication can result in low self esteem and psychological disengagement, and can have a negative impact on the Quality of Life (QOC). This is one area of investigation conducted during a state/federal survey.

When communicating with a resident, the nurse should tell him/her in straightforward language what has to be communicated and ask if the resident understood what was said.

Barriers to good communication can include language differences, hearing problems, hearing aide inefficiency and environmental reasons, such as background noises, loud music and too frequent overhead paging.  These barriers need to be corrected. Inservice education should be available on communication skills. Also, caregivers need to recognize residents’  emotional  conflicts and how they can affect communication with the residents. During periods of care, discussion on the resident’s previous work, hobbies, family and travel experiences will engage the resident in a meaningful way.

On one occasion a resident remarked to me about a specific caregiver.

She stated the caregiver discussed  observations made on the way to work, weather, shopping experiences and interactions with others. The resident said ”I love when she is assigned to me as it gets me out of this room”.

It is very important that the nurse communicates with family frequently pertaining to any changes in the resident’s condition. Good communication goes a long way in alleviating stress and concerns, and helps to decrease any negative perceptions of the care provided by the facility.

When family knows they will be notified timely of any changes or concerns and are encouraged to participate in the resident’s care, they identify a partnership and become more trusting. The family should be notified of all relevant issues pertaining to the resident including changes in condition, medications, treatments and physician visits.

Good communication skills are beneficial when giving reports to the physician. Use of the INTERACT tool SBAR ( Situation, Background, Assessment and Request) should enable the nurse to make a good assessment and have a detailed report available. Physicians frequently say that the nurse did not provide an adequate report, resulting in the resident ‘s transfer to the hospital emergency department for evaluation and treatment.

All nurses should have access to  the  Minimum Data Set (MDS) which should help increase Interdisciplinary Team (IDT) communication.

All team members should be ready for a discussion of the resident’s condition at the care plan conference. When staff are assigned to work together on a project as an IDT, understanding and communication will be enhanced.

Documentation is the written form of communication. We all have heard the old cliche :   “If it wasn’t written down, it wasn’t done.”

Nursing documentation must provide an accurate and timely account of occurrences and must be reflective of observations, be legible and permanent.

Good documents  has six important characteristics:

Factual

Accurate

Complete

Current (timely)

Organized

Compliant with standards

The nurse should follow the policies of the facility, especially the  appropriate measures for correcting documentation errors. Charting requirements for Medicare residents should be complete and thorough.

If the nurse is unsure that her documentation is satisfactory, she should ask herself, “If another nurse had to take over for me right now, does the charting have enough information for the delivery of safe, competent and ethical care?”

Remember the resident’s record is a legal document. Documentation should provide a chronological record of events so that an ordered sequence or time line is easily recognized. Should the record be reviewed by a legal team, the nurse will be held accountable for lack of clarity. All documentation must be legibly signed and dated.