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.

Observations, Reporting and Team Work

                         Observations, Reporting and Team Work

All nursing shifts should make frequent observations on a new resident, especially for the first 72 hours. This information is the basis for the development of a good careplan (CP). As the resident settles in and becomes acquainted with other residents and staff, you will often see a personality change. He or she sleeps better, is more relaxed and becomes involved in the routine of the facility. The charge nurse should meet with all shift direct care personnel to identify patterns for the Activities of Daily Living (ADLs), sleeping, eating, going to the toilet and any expressed concerns (such as pain), should also be identified and investigated. Awareness of the resident’s religious affiliations should also identified as he or she may wish to attend religious services provided by the facility.  

The other care disciplines involved in the resident’s care should also communicate their particular findings. That is the best way to begin the interdisciplinary care plan (IDC). All new interventions, involving the resident must be entered in the CP and updated or changed as necessary.

It has been my experience, that involving the Power of Attorney (POA) or family as much as possible is always a positive factor. The resident must also be allowed to participate in the CP if he is  adequately cognizant.

The other disciplines who are involved in a resident’s care, as needs are identified, are Dietary, Activities, Social Service and the Therapy Department, including Physical, Occupational and Speech. Also Rehabilitation/Restorative therapy may be included in the IDC. As the assessments are completed and care needs identified, the IDC will be established. As these various disciplines interact with the resident, sometimes on a daily basis, please be aware that Nursing interventions are 24/7.

It is imperative in care of the residents to have a good team approach. An acronym for team which is well known is

T--- Together

E----Each

A----Achieve

M----More

I have received many useful reports on observations made by maintenance, housekeeping and dietary staff but then I always encouraged the input and showed my appreciation for the information.

In some facilities, I have seen the INTERACT tools in use. (http://interact2.net/index.aspx) One of these tools which I have found very useful is the Early Warning Tool “Stop and Watch”. It can be used by the direct care staff or any department personnel, to provide input to the nurse.

Written statements concerning resident care are more beneficial than verbal ones, especially if the nurse is busy with the medication pass or on the phone with the physician or family.  A verbal statement may be misinterpreted or easily forgotten. All staff should share information that enables timely decision making by the direct resident care team. Feedback between staff should be delivered in a way that promotes positive interactions. All staff should understand their roles and responsibilities and should be held accountable for their actions.

Admission, Transition and Assessment of a New Resident

Having a good admission process will benefit the resident  during their stay in the facility. Greet the resident by name and welcome him or her to your facility. It is vital that a good assessment should be completed and documented as quickly as possible post admission. Tell them your name and position. Ask them how they would like to be addressed (Robert versus Bob, for instance). Get as much information as possible directly from the resident if they are cognizant or from the accompanying relative or power of attorney (POA), including history of any past illness. Introduce the resident to their roommate if they are sharing a room. It is important to realize if the resident is having a difficult time transitioning from home, hospital or other long term care facility. The resident will be amongst strangers again and may be suspicious, cantankerous and not compliant. It is your responsibility to ease their distress by being polite and caring.

Always remember that first impressions go a long way. You need to do a head to toe assessment specifically concentrating on the admitting diagnosis.

Scalp and hair: Any lesions or dandruff present?

Eyes: Glasses, contact lenses, cataracts removed.

Ears: How is the resident’s hearing? Do they use hearing aids?

Nose: Any history of Epistaxis (nosebleeds)?

Mouth: Do they have their own teeth? Edentulous (possessing no teeth). Is there any sores or redness?

Neck: Check for any swelling.

Lungs: Auscultation(using a stethoscope) the chest thoroughly. Any complaints of cough or shortness of breath?

Does the resident have a pacemaker? When was it last checked.? Check apical and radial pulses and heart sounds.

Check nail beds for any signs of cyanosis.

Breast examination: Observe for symmetry, bulging, retraction or fixation. Palpate the breast in a clockwise rotary motion. The areolas should be palpated to determine the presence of underlying masses. The nipples should be gently compressed for any discharge.

Abdomen: should be assessed for contour and distention. Any signs of peristalsis. Respiratory movement should be assessed. Observe for lesions, scar tissue, striae veins, and pigmentation. Check the umbilicus for any swelling. You may see aortic pulsation in very thin residents.

Use your stethoscope lightly to detect bowel sounds. You should listen in all quadrants for at least five minutes. Check for tenderness and muscle guarding.

Extremities: Observe for involuntary movement. Check the size, contours and bilateral symmetry. Check for edema, color, temperature and pluses. Preform range of motion and check for muscle strength. Check for tonicity of muscle.

Skin: a complete skin sweep must be performed. Observe for skin tears, bruises, scratches, scars and any signs of pressure sores (We are all aware of the difference between “admitted with’ versus “acquired at facility”). If possible, measurements and photographs should be taken (if it is your facility’s policy).

The other assessments required by your facility, fall risk, bowel and bladder, pain, etc., should all be completed timely. All your observances should be in the documentation, signed and dated. Base height, weight and vital signs should be recorded. Check the ability of the resident to care for glasses, hearing aids and dentures, if present. Do they require assistance?

I have decided to create a blog on some of the current problems relative to Long Term Care (LTC) facilities. It is my hope that discussing these issues will provide a helpful tool for caregivers. We are all aware that the acuity levels of residents’ illnesses have escalated dramatically and residents that are presently discharged very quickly post acute stage to LTC facilities.

All LTC employees should be aware of the federal regulations and state agency guidelines required to enable the facility be certified by Centers for Medicare and Medicaid (CMS) and licensed by the state.  This certification and licensure enables the facility participate in the Medicare and Medicaid reimbursement programs.

State and/or federal surveyors visit LTC  facilities at least annually to determine if these standards are maintained and to ensure the residents are receiving appropriate care.

I have worked in many areas of LTC over the past 40 years. Having concentrated on the overall  of resident care needs I have developed the Ten Commandments of LTC:

1. Admission, transition and assessment of a new resident.
2. Observation and reporting and Team work.
3. Complaints and Communication.
4. Falls, Incidents and  Accidents.
5. End of Life care POLST.
6. Psychotropic medication reduction.
7. Diabetic management.
8. Infections including UTI problems
9. Hospital readmission avoidance.

     (10) Dehydration and weight variance.     

These are not listed in any order of importance and are frequently interrelated. I will discuss these issues in future blogs.