New Nursing and Long Term Care Resources

The LTCS Books site now features a number of very useful resources for nurses and long term care professionals.

The new page State Long Term Care and CNA Regulations has links to each state’s Medicaid program, long term care administrative codes, department of health, and certified nursing assistant training and certification regulations. All of LTCS long term care and home health books are up to date with the latest federal regulations, surveyor guidelines, MDS 3.0, and OASIS-C changes. Now you can download the latest regulatory changes for your state.

Online nursing inservices with narration and graphics make learning a pleasure, and are available at a bargain price.

Books are now available as downloads through Google EBooks.

Look inside each book and view its contents on the Amazon author page for LTCS Books author Debra Collins, RN, RAC-CT.

The new Guide to Online RN to BSN Degrees is a complete guide to every online RN program in the U.S. For each state, online programs are listed and described for every university, giving the exact cost per credit hour and with a link directly to the university’s online RN to BSN or RN to MSN program.

99 Google Plus Accounts All Nurses Should Follow

LPN to BSN Online writes, “Nurses in all specialties will find something useful on Google Plus, and the pages listed in this category cover a wide swath of subject matter suited for just about anyone who wears scrubs to work.”

LTCS Books author Debra Collins, RN, RAC-CT is one of the 99 listed.

“One online venue where many nurses and nursing organizations have started connecting with each other is Google Plus,” writes LPN to BSN Online.

“Many hospitals, clinics, and individual nurses use their Google Plus accounts to share news tidbits and discuss the pressing matters that affect the explosively growing field of nursing.

These Google Plus accounts represent individuals and groups from across the nursing spectrum. This list isn’t a ranking, but a repository of great accounts and communities that any nurse who uses Google Plus should follow. Whether you’re a beginning nursing student or experienced pro, you can make friends and even find your next career opportunity through Google Plus.”

99 Google Plus Accounts All Nurses Should Follow

Debra Collins on Google Plus

Nursing Care Plan Evaluation

Evaluation of the nursing care plan is an ongoing activity that examines the care plan problem itself, the care plan goals, and the care plan interventions to determine if they are still applicable or if changes to the care plan need to be made. 

Reasons for changing the nursing care plan may be:

The problem is resolved

Goals were met

Goals need to be bigger or smaller

A new diagnosis or change in the resident’s condition is impacting the problem

New medications or treatments need to be included 

The interdisciplinary care plan team should review the resident’s entire nursing care plan at each care plan meeting, and make the necessary changes. Nurses notes should address the care plan with each monthly summary.

Read more about how to write nursing care plans in the book Complete Nursing Care Plans for Long Term Care - 143 nursing care plans in the book and on the CD can be made resident specific and converted to I-care plans in one click.

RN to BSN Programs Vary by State

Increasingly, hospitals and larger health care corporations are hiring only RNs with BSN degrees, but there is a great variation in state availability of online RN program offerings. Online courses make it much easier for working RNs to fit classes into their busy schedules.

Some states have only one or two online RN to BSN programs, others have as many as twelve.

There is also a large variation in the cost of program tuitions, with some universities charging as much as $490 per credit hour, and others as little as $190 per credit hour.

Find the program that is just right for you in the LTCS Guide to Online RN Programs, a complete guide to every online RN to BSN and RN to MSN program in the U.S.

For each state online programs are listed and described for every university, giving the exact cost per credit hour and with a link directly to the university’s online RN to BSN or RN to MSN program.

Guide to Online RN Programs

Nursing Care Plan Interventions

Nursing care plan interventions describe specific actions taken by long term care staff members o achieve the stated goal, and are based on standards of clinical practice. 

The Code of Federal Regulations, F281, states that the services provided or arranged by the facility must meet professional standards of quality and be provided by qualified persons in accordance with each resident’s written nursing care plan. 

Like goals, interventions need to be specific, measurable, appropriate, and realistic. Interventions are worded in terms of what the staff will do to assist the resident to meet the stated goals for the problem, such as: 

Offer resident four ounces of fluid eight times per day. 

“Professional standards of quality” means services that are provided according to accepted standards of clinical practice. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. 

Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include such sources as: 

Current manuals or textbooks on nursing, social work, physical therapy, etc. 

Standards published by professional organizations such as the American Dietetic Association, American Medical Association, American Medical Director’s Association, American Nurses Association, National Association of Activity Professionals, etc. 

Clinical practice guidelines published by the Agency of Health Care Policy and Research 

Current professional journal articles 

Read more about how to write nursing care plans in the book Complete Care Plans for Long Term Care - 143 nursing care plans in the book and on the CD can be made resident specific and converted to I-care plans in one click.

Writing Nursing Care Plan Goals

The nursing care plan goal can be to prevent a potential problem from occurring, to maintain a present status or level of functional ability, or to resolve a currently existing problem. Goals are usually stated in terms of an action the resident will perform. Elements to focus on in writing the goal are that it is: 

Appropriate – for the resident’s needs, strengths, abilities, and cultural background 

Realistic – reasonably attainable 

Measurable – able to be objectively observed and evaluated 

Resident centered – stated in terms of the resident’s actions 

Time framed – gives a target date or time estimate for attainment of the goal 

Individualized – to the resident’s unique deficits, traits, and preferences 

Specific – each problem has a goal specific to it, although each problem may have more than one goal 

Examples: 

Resident will wash face and hands during morning care every day.

Resident will verbalize understanding of the need to comply with diabetic diet. 

Resident will lose one pound per week over the next thirty days.

Read more about how to write nursing care plans in the book Complete Nursing Care Plans for Long Term Care - 143 nursing care plans in the book and on the CD can be made resident specific and converted to I-care plans in one click. 

Finding the Best RN to BSN Online Programs

Weeding through Internet information overload can be difficult when it’s very specific information you want. LTCS Books’ newGuide to Online RN Programs makes this way easier.

For each state online programs are listed and described for every university, giving the exact cost per credit hour and with a link directly to the university’s online RN to BSN or RN to MSN program.

At a glance, find out exactly which universities are offering online RN degrees in your state and exactly what the cost of tuition is. Some programs charge as little as $270 per credit hour, others can run as high as $800 per credit hour. What a difference that can make to a budget!

Having the direct links to the programs enables you to examine the strengths and weaknesses of each program in your state.

Guide to Online RN Programs

Writing Care Plan Problem Statements

The problem statement sums up assessment information into a specific functional category. No federal regulation specifies the exact wording or structure of the problem statement, but theMDS 3.0 RAI Users Manual states that problems should be written in functional or behavioral terms. 

Problem statements are traditionally based on a nursing diagnosis. The nursing diagnosis is a problem that nurses can identify and treat. Medical diagnoses can be part of the problem statement, but not the actual problem itself. The most commonly used nursing diagnoses are the ones approved by NANDA, the North American Nursing Diagnosis Association, and are grouped by functional health patterns. 

Elements often included are:

Whether the problem is actual or potential

What the problem is related to, such as medical diagnosis

Objective signs and symptoms of the problem, such as physical assessments and observations

Subjective data, such as the resident’s complaints and nonverbal messages 

The first part of the problem statement describes the resident’s actual or potential functional deficit:

Activity Intolerance 

Medical diagnoses can be added to the statement with the words “related to”:

Activity Intolerance related to COPD 

Objective and subjective data can be specified in the form of the words “as evidenced by”:

Activity Intolerance related to COPD

As evidenced by:

Shortness of breath

Resident verbalizes fatigue when walking in corridor 

Federal regulations are specific that the facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS orCare Area Assessments (CAAs). 

A sound practice for care-planning is to follow a check-list of problem identification: 

Address all problems triggered in the CAAs.

Review MDS sections and entries.

Review the resident’s entire chart.

Review the resident’s list of medical diagnoses and all medications.

Focus on the resident’s particular and individual strengths, needs, and preferences. These may become clearer during the care plan meeting, working with the care plan team.

Review the Quality Indicators and Quality Measures triggered by the MDS.

Read all quarterly assessments such as falls, restraints, etc.

The problem should be dated and initialed when entered, changed, or deleted. 

Complete Nursing Care Plans for Long Term Care - 143 Nursing Care Plans for Long Term Care in the book and on the CD 

ADA Says Expand Dental Care for Nursing Home Residents

Over one million nursing home residents face barriers to accessing adequate dental care, according to a recent policy statement by the American Dental Association, Action for Dental Health.

Presently, long term care facilities must cover the cost of dental care for residents.

The ADA recommends expanding the public health system to cover the cost of dental care for long term care facility residents. 

Action for Dental Health 

Dental Care and Nursing Care Plans

Coding Section L of the MDS 3.0, Dental Care

Resident-to-Staff Aggression is a Common Problem

Resident verbal and physical aggression is most common during morning care, says a recent article in the Journal of General Internal Medicine.

The article concludes that since resident-to- staff aggression has such a negative impact on job performance and staff satisfaction, much more research is needed to develop interventions to decrease resident aggression. 

Verbal and Physical Aggression Directed at Nursing Home Staff by Residents

Behavior Care Plans 

Anger Care Plan

Online Nursing Assistant Behavior Inservice 

Coding Section E, Behavior

Urinary Incontinence is Costly to Health and Finances

Although the prevalence of urinary incontinence is 51% among women and 14% among men, it is significantly under-reported by patients and under-diagnosed by clinicians, according to a recent article by Home Healthcare Nurse. 

Financial costs for women older than 65 years of age are $7.6 billion per year. 

Urinary incontinence is also very costly to health. It is a frequent cause of falls in older adults, related to hurrying to try to get to the bathroom in time. 

Physical results of urinary incontinence often include pressure sores, urinary tract infections, institutionalization, depression, isolation, and decreased mobility. 

Identifying Urinary Incontinence in the Home Setting – Home Healthcare Nurse 

Facility Program for Urinary Incontinence 

Restorative Programs for Urinary Incontinence

Nursing Care Plans for Urinary Incontinence 

Online CNA Inservice for Toileting and Elimination

Abuse Prevalence in Long Term Care

The statistics will shock you. During 1999-2001, nearly 1 in 3 U.S. nursing homes were cited for violations that had potential to cause harm or that had caused actual harm to a resident.  

Educating staff members on abuse prevention is more important than ever, and should always be part of yearly inservice training.  

UC Irvine’s Center of Excellence on Elder Abuse and Neglecthas some great resources for abuse education, and is the world’s first Elder Abuse Forensic Center, bringing together physicians, psychologists, law enforcement, social workers and others to handle complex cases.  

The center hosts the Elder Abuse Training Institute which identifies the most pressing training needs in elder mistreatment, and was recently named by the U.S. Administration on Aging as the National Center on Elder Abuse.  

Download their printable brochure Abuse of Residents of Long Term Care Facilities and read detailed facts and statistics about elder abuse.  

Check out this comprehensive and affordable online inservice for Preventing Resident Abuse . 

Care Plans and Preventing Avoidable Declines

Surveyors will investigate if the resident declined or failed to improve relative to expectations, and determine if this was avoidable or unavoidable.
The Care Plan is a record that describes the resident’s functional abilities at different times of the past year. Make sure the documentation is comprehensive and genuinely reflects the resident’s abilities. If the goals are realistic and regularly measured, it will help to identify declines.
Surveyors will focus on the Late-loss ADLs, those considered to be the last to decline or deteriorate: Bed Mobility, Transfer, Eating, and Toilet Use. They will use the Quality Indicators and the Quality Measures, and evaluate occurrences and preventative measures.
The Admission Assessment and Care Plan should accurately document the resident’s mobility, range of motion, transfer ability, and balance. Evaluations from Physical Therapy, Occupational Therapy, and Restorative Nursing will give in-depth information about the resident’s level of functioning.

Nursing Care Plans and CAA Documentation

The goal in documenting the Care Area Assessment process is to identify what needs to be care-planned, and why or why not. The documentation should include the problem, contributing and risk factors, and state if improvement is possible or decline can be minimized. 

CAA Summary notes should be brief but cover the essential points. Documentation for each triggered CAA should generally describe:

 Nature of the issue or condition (may include presence or lack of objective data and subjective complaints).

Complications and risk factors that affect the staff’s decision to proceed to care planning. 

Factors that must be considered in developing individualized care plan interventions. Include appropriate documentation to justify the decision to care plan or not to care plan for the individual resident. 

Need for referrals or further evaluation by appropriate health professionals. 

Written documentation of the CAA findings and decision-making process may appear anywhere in the resident’s record. 

The documentation can be located anywhere in the resident’s chart, and any form of CAT Summary Note is acceptable. 

It can be written in discipline specific flow sheets, progress notes, in the care plan summary notes, in a CAA summary narrative, on a CAA questionnaire, etc.

No matter where the information is recorded, use the “Location and Date of CAA Assessment Documentation” column on the CAA Summary form to note where the CAA review and decision-making documentation can be found in the resident’s record.  Also indicate in the column “Care Plan Decision” if the triggered problem is addressed in the care plan.

Refer to the location and date of this documentation on the CAA Summary Form, which is section V of the MDS. 

Using the right CAA Modules in this manual will make the process much easier.

Care Area Assessment Book with Triggers and Modules

CAA Nutritional Status

CAA Cognitive Loss – Dementia

Boost Quality Assurance with QA Audit Forms

Get the most from your Quality Assurance department by using facility program audit forms.

An Admission Documentation audit is a fast and efficient way to make sure every essential assessment is completed and documented at admission.

A Facility Fall Prevention Program audit quickly assesses if your facility has everything in place to prevent and monitor resident falls and improve facility practices and procedures.

Keep track of unnecessary medications and adverse consequences with a Facility Medication audit.

Quality Assurance audit forms help the Director of Nursing and Administrator view the overall performance and consistency of facility practices and to pinpoint problematical areas of performance.

Debra Collins, RN, RAC-CT

As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term careand home health care federal regulatory changes.

She has written and published manuals for long term care and home health care documentation on nursing care plans, restorative nursing care plans,social service care plans, activities care plans, home health nursing care plans, home health nursing inservices, MDS 3.o forms for the MDS Coordinator, resources for theDirector of Nursing in long term care, nursing policy for long term care, long term care inservices, infection control for long term care, and Medicare/Medicaid documentation. The books are used by over one third of long term care facilities in the United States.

Debra has over 25 years experience in long term care and home health care. She worked as an MDS Consultant for many years, and is certified as a Resident Assessment Coordinator by AANAC, the American Association of Nurse Assessment Coordinators.

She is a member of the Bloomington Indiana Chamber of Commerce, National Nurses in Business Association, National Association for Female Executives, American Business Women’s Association, andLadies Who Launch.

Amazon Author Page Debra Collins, RN, RAC-CT

Good Nursing Policies and Procedures are the Blueprint for Quality Care

A long term care facility’s Nursing department policy and procedure manual should outline administrative policies and standards of care for basic nursing care procedures and all basic clinical practices.

It is the Director of Nursing’sresponsibility to review and update the manual at least annually to assure it is comprehensive and accurate. Updates must also be made when applicable due to changes in regulations or nursing standards of practice.

The master copy should be kept in the Director of Nursing’s office, and one copy placed at each nurses’ station so when policy or procedure is in doubt, staff can refer to the manual for clarity. To make it easier for staff to find subjects, it’s best if the manual includes a table of contents and an alphabetized cross-index.

The standard format for a procedure includes:

Statement giving objective goal of policy or procedure

Equipment and material needed

Staff the policy applies to, staff authorized to perform procedure

Documentation guidelines

Some facilities include in the policy and procedure manualmaster copies of long term care nursing forms. This helps to ensure uniform documentation throughout the facility.

Examples of policy and procedure manual topics:

Admissions and discharges

Blood sugar monitoring

Dressing changes

Feeding Tube

Isolation protocols

Lifts and transfers

Medication Errors

Post-fall protocol

Range of motion

Restraints

Standard precautions

Tracheostomy care

Urinary catheter insertion and care

Read more about topics of interest to the DON in long term care in the book Nursing Policy for Long Term Care and in the book  Director of Nursing Book .