Nursing Assistant in Long-Term Care Notes
Long-Term Care vs. Other Healthcare Settings
Healthcare settings are diverse, with nursing assistants working in many. While tasks may overlap, each setting has unique aspects.
Long-term care (LTC) is provided in LTC facilities, offering 24-hour skilled care for those needing ongoing medical attention.
Skilled care is medically necessary and administered by trained nurses or therapists under a doctor's orders.
LTC facilities may also be known as skilled nursing facilities (SNFs), rehabilitation centers, or extended care facilities.
Residents in LTC facilities are often elderly or disabled, with stays ranging from short-term to longer than six months.
Some residents might have terminal illnesses, while others recover and return home or to other care settings.
Chronic conditions like physical disabilities, heart disease, and dementia are common among LTC residents.
Residents reside in these facilities, which become their homes for the duration of their stay (Fig. 1-1).
Each resident's care plan is tailored to their individual diagnoses, symptoms, abilities, and needs.
Alternative Healthcare Settings
Home health care (home care): Provides services in a person's home, often for older, chronically ill individuals who wish to stay at home (Fig. 1-2).
Assisted living facilities: Offer residences for individuals needing help with daily tasks but not requiring 24-hour skilled care.
Allow for more independent living in a homelike setting.
Adult day services: Supervise and assist individuals during specific hours, providing a break for family caregivers.
Suitable for those needing some help but not seriously ill or disabled.
Acute care: Delivers 24-hour skilled care in hospitals and surgical centers for short-term, immediate illnesses or injuries (Fig. 1-3).
Subacute care: Provided in hospitals or LTC facilities for those needing more care than chronic illness management but less than acute care.
Outpatient care: Short-term skilled care after treatments, procedures, or surgeries without an overnight stay.
Rehabilitation: Specialized care to restore or improve function after illness or injury, involving physical, occupational, and speech therapists.
Hospice care: Given in facilities or homes for individuals with six months or less to live, focusing on physical and emotional comfort and family support.
Long-Term Care Facilities
LTC facilities operate as businesses providing 24/7 skilled nursing care.
Offer various services, including assisted living, dementia care, and subacute care.
Facilities may offer specialized care or cater to all types of residents.
Typical services include personal care (bathing, grooming, dressing, etc.) and specialized care for residents with specific needs.
Personal care tasks are known as activities of daily living (ADLs).
Other services include physical, occupational, and speech therapy, wound care, and nutrition therapy.
Management of chronic diseases like Alzheimer's, AIDS, diabetes, COPD, cancer, and CHF is also provided.
Employees require specialized training for specialized care units.
Facilities can be owned by nonprofit or for-profit companies.
Person-Centered Care
Person-centered care focuses on the individual and their capabilities, promoting preferences, choices, dignity, and interests.
Respects each person's background, culture, language, beliefs, and traditions.
Aims to improve each resident's quality of life.
Trauma-Informed Care
Trauma-informed care recognizes that people may have experienced trauma.
Examples: abuse, neglect, violence, prison, military combat, unstable home environments, poverty, discrimination, life-threatening illness, or negative experiences in a medical setting
Medicare and Medicaid
The Centers for Medicare & Medicaid Services (CMS) oversees the Medicare and Medicaid programs.
Medicare: A federal health insurance program established in 1965 for people aged 65 or older, and those with permanent kidney failure or certain disabilities.
Part A: Covers care in hospitals, skilled nursing facilities, home health, or hospice.
Part B: Covers doctor services, medical services, and equipment.
Part C: Allows private health insurance companies to provide Medicare benefits.
Part D: Covers prescription medications.
Medicare only pays for medically necessary care.
Medicaid: A medical assistance program for people with low incomes and disabilities, funded by the federal government and each state.
Eligibility is determined by income and special circumstances.
Medicare and Medicaid pay LTC facilities a fixed amount based on the resident's needs.
Nursing Assistant's Role
A nursing assistant (NA) performs assigned nursing tasks and provides personal care.
Common duties include bathing, assisting with elimination, range of motion exercises, ambulation, transferring residents, measuring vital signs, assisting with meals, dressing, backrubs, mouth care, bed making, and maintaining cleanliness (Fig. 1-4).
Promoting independence and self-care is a crucial aspect of the NA's job.
NAs cannot insert or remove tubes, give tube feedings, or change sterile dressings.
Some states allow NAs to administer medications after completing specialized training.
Observing and reporting changes in a resident's condition is a vital duty.
Charting or documenting important information is another key responsibility.
NAs are part of a healthcare team including doctors, nurses, social workers, therapists, dietitians, specialists, residents, and their families.
The team works together to help residents recover and maximize their independence.
Different titles for nursing assistants exist, such as nurse aide, certified nurse aide, patient care technician, and certified nursing assistant.
Responsibility for all residents is shared among nursing assistants, even if they are not specifically assigned to them.
Care Team and Chain of Command
Healthcare professionals with diverse education and experience form the care team.
Members include:
Nursing Assistant (NA): Performs assigned tasks and assists with personal care; requires at least 75 hours of training.
Registered Nurse (RN): Coordinates, manages, and provides skilled nursing care; licensed professional with a two- to four-year nursing program.
Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN): Gives medications and treatments; licensed professional with one to two years of education.
Advanced Practice Registered Nurse (APRN): Registered nurse with postgraduate training; can make diagnoses and prescribe treatment.
Physician or Doctor (MD or DO): Diagnoses disease and prescribes treatment and medication (Fig. 1-5).
Physician Assistant (PA): Diagnoses disease and develops treatment plans under a doctor's supervision.
Physical Therapist (PT or DPT): Develops treatment plans to increase movement, improve circulation, reduce pain, and regain mobility (Fig. 1-6).
Occupational Therapist (OT): Helps residents adapt to disabilities and perform ADLs using assistive devices.
Speech-Language Pathologist (SLP): Identifies communication disorders and develops a plan of care.
Registered Dietitian (RD or RDN): Assesses nutritional status and develops treatment plans to improve health and manage illness.
Medical Social Worker (MSW): Determines residents' needs and helps get them support services.
Activities Director: Plans activities to help residents socialize and stay active.
Resident and Resident's Family: Essential members of the care team; their well-being is the priority.
The resident is the most important member of the care team.
The chain of command outlines the line of authority, ensuring proper healthcare and protecting employees and employers from liability (Fig. 1-7).
Liability refers to being held responsible for harming someone else.
NAs must understand their scope of practice to avoid harming residents or causing legal issues.
Scope of practice defines legally permissible tasks for healthcare providers.
The care plan is individualized and details tasks, services, and treatments.
Includes diagnoses, limitations, goals, interventions, and required supplies and equipment.
Care planning involves input from residents, families, and healthcare professionals.
NAs must carefully follow the care plan and report observations to the nurse.
Policies, Procedures, and Professionalism
Facilities have policies (courses of action) and procedures (methods of doing things) that staff must follow.
Examples of policies:
Resident information must remain confidential.
The care plan must always be followed.
Tasks not in the job description should not be performed.
Report important events or changes in residents to a nurse.
Do not discuss personal problems with residents or their families.
Do not take money or gifts from residents or their families.
Be on time and dependable.
Professionalism is behaving properly on the job, including appropriate attire, good communication, punctuality, task completion, and reporting.
A professional relationship with residents includes:
Providing person-centered care
Maintaining a positive attitude
Performing only assigned and trained tasks
Maintaining confidentiality
Being polite
Avoiding personal discussions
Accepting directions or feedback
Maintaining cleanliness and grooming
Being punctual
Following the chain of command
Avoiding personal phone use
Using respectful language
Using preferred pronouns
Never giving or accepting gifts
Explaining care before providing it
Following safety practices
A professional relationship with an employer includes:
Completing tasks efficiently
Following policies and procedures
Documenting and reporting accurately
Reporting problems
Asking questions when needed
Participating in education programs
Being a positive role model
Important qualities for NAs:
Compassionate: Caring, empathetic, and understanding.
Honest: Truthful and trustworthy.
Tactful: Sensitive and appropriate in interactions.
Conscientious: Dedicated to doing their best.
Dependable: Reliable and committed.
Patient: Showing tolerance and understanding.
Respectful: Valuing individuality.
Unprejudiced: Giving equal care regardless of background.
Proactive: Anticipating needs and preventing problems.
Legal and Ethical Behavior & Resident Rights
Ethics (knowledge of right and wrong) and laws (government rules) guide behavior.
NAs must be guided by a code of ethics and applicable laws.
Guidelines for Legal and Ethical Behavior:
Be honest at all times.
Protect residents' privacy and confidentiality.
Keep staff information confidential.
Report abuse or suspected abuse.
Follow the care plan and assignments.
Report mistakes promptly.
Do not perform tasks outside your scope of practice.
Report all resident observations and incidents.
Document accurately and promptly.
Follow safety and infection prevention rules.
Do not accept gifts or tips (Fig. 1-10).
Do not get personally or sexually involved with residents or their families.
The Omnibus Budget Reconciliation Act (OBRA) of 1987 set minimum standards of care and standardized NA training.
OBRA requires:
Nurse Aide Training and Competency Evaluation Program (NATCEP) with at least 75 hours of training.
Competency evaluation (test) for NAs.
Minimum of 12 hours per year of in-service education.
State registry of nursing assistants.
Minimum staff requirements and specific services in LTC facilities.
Resident assessment requirements.
Surveys are inspections to ensure LTC facilities follow regulations.
Resident's Rights:
Specify how residents must be treated.
Quality of life: Right to the best care available; dignity, choice, and independence are important.
Services and activities to maintain wellness: Care plans must be developed to keep residents as healthy as possible.
Right to be fully informed: Residents must be told about services, fees, and their legal rights.
Right to participate in their own care: Residents can participate in planning treatment, care, and discharge.
Right to make independent choices: Residents can make choices about care and personal decisions.
Right to privacy and confidentiality: Right to private communication and confidentiality regarding all aspects of their lives (Fig. 1-11).
Right to dignity, respect, and freedom: Must be treated with dignity and not be abused, mistreated, or neglected.
Right to security of possessions: Personal possessions must be safe.
Rights during transfers and discharges: Residents must be informed of and consent to location changes.
Right to complain: Residents can make complaints without fear.
Right to visits: Right to visits from doctors, family, friends, etc.
Rights with regard to social services: Access to counseling and assistance.
Guidelines for Protecting Residents' Rights:
Never abuse a resident.
Call the resident by their preferred name and pronouns.
Involve residents in planning care.
Explain procedures before performing them.
Do not unnecessarily expose residents.
Respect a resident's refusal of care, and report it to the nurse.
Tell the nurse if a resident has questions, concerns, or complaints.
Be truthful when documenting care.
Do not gossip about residents.
Knock before entering a resident's room (Fig. 1-12).
Do not accept gifts or money.
Do not open a resident's mail or look through their belongings.
Respect personal possessions.
Report observations about a resident's condition or care.
Help resolve disputes.
Maintaining Boundaries in professional relationships is essential to support a healthy staff-resident dynamic.
Abuse and Neglect
Abuse is purposeful mistreatment causing harm, including:
Physical abuse: Causes harm to a person's body.
Psychological abuse: Emotional harm caused by threats, intimidation, or isolation.
Verbal abuse: Use of words, pictures, or gestures that threaten, embarrass, or insult a person.
Sexual abuse: Nonconsensual sexual contact.
Financial abuse: Improper or illegal use of money or possessions.
Assault: A threat to harm.
Battery: Intentional touching without consent.
Domestic violence: Abuse by family members.
False imprisonment: Unlawful restraint.
Involuntary seclusion: Separation from others against their will.
Workplace violence: Abuse of staff by other staff members, residents, or visitors.
Sexual harassment: Unwelcome sexual advances.
Substance abuse: Harmful use of drugs or alcohol.
Neglect is failure to provide needed care.
Negligence is actions or inactions resulting in unintended injury.
Malpractice occurs when injury results from professional misconduct.
Injuries That Should be Reported:
Poisoning or traumatic injury
Teeth marks
Belt buckle or strap marks
Bruises, contusions, or welts
Scars
Fractures or dislocations
Burns of unusual shape and in unusual locations, or cigarette burns
Scalding burns
Scratches or puncture wounds
Scalp tenderness or patches of missing hair
Swelling in the face, broken teeth, or nasal discharge
Bruises, bleeding, or discharge from the vaginal area
Signs of Abuse:
Yelling obscenities
Fear, apprehension, or fear of being alone
Poor self-control
Constant pain
Threatening to hurt others
Withdrawal or apathy (Fig. 1-13)
Alcohol or drug abuse
Agitation, anxiety, or signs of stress
Low self-esteem
Mood changes, confusion, or disorientation
Private conversations not allowed, or the family member/caregiver present during all conversations
Reports of questionable care by the resident or her family
Signs of Neglect:
Pressure injuries
Unclean body
Body lice
Unanswered call lights
Soiled bedding or incontinence briefs not being changed
Poorly fitting clothing
Unmet needs relating to hearing aids, eyeglasses, etc.
Weight loss or poor appetite
Uneaten food
Dehydration
Fresh water or beverages not being offered regularly
Resident reports not receiving prescribed medication
NAs must report suspected abuse immediately to the nurse in charge.
If no action is taken, report up the chain of command until action is taken or call the state abuse hotline.
Ombudsmen are legal advocates for residents, monitoring care and conditions (Fig. 1-14).
Confidentiality and HIPAA
Confidentiality requires keeping private things private.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 protects health information.
Protected health information (PHI) is information that can identify a person and relates to their condition, healthcare, and payment.
PHI examples: name, address, phone number, social security number, email address, and medical record number.
HIPAA applies to all healthcare providers.
NAs cannot give out resident information to anyone not directly involved in care without consent.
Guidelines for Protecting Privacy:
Ensure privacy when listening to or reading messages.
Verify with whom you are speaking on the phone before sharing information.
Do not talk about residents in public (Fig. 1-15).
Use confidential rooms for reports to other care team members.
Be careful with greetings to family members or former residents in public.
Do not bring family or friends to meet residents.
Protect health information on computer screens and log out when finished.
Do not give confidential information in emails.
Do not share resident information, photos, or videos on social networking sites or via text messages.
Verify fax numbers before faxing and use a cover sheet with a confidentiality statement.
Do not leave documents where others may see them and store, file, or shred them according to facility policy.
HIPAA violations can result in fines (100 to $$1.5 million) and prison sentences (up to 10 years).
Medical Records
The resident's medical record or chart is a legal document.
If it is not documented, it was not done.
Careful charting is important because:
It ensures clear communication among the care team.
It is a legal record of treatment.
It protects NAs and employers from liability.
It provides an up-to-date record of the resident's status and care.
Guidelines for Careful Documentation:
Document care immediately after it is given.
Think before documenting, be brief and clear, and use facts, not opinions.
If your facility uses electronic documentation, you will be trained how to do this.
The legal documentation rules apply to both electronic and paper medical charts.
HIPAA privacy guidelines apply to electronic documentation. Make sure nobody can see protected health information.
Use black ink when documenting by hand.
Write neatly.
If you make a mistake, draw one line through it, write the correct information, and initial and date it; do not erase or use correction fluid.
Sign your full name and title (e.g., Sara Martinez, NA) and write the correct date.
Document as specified in the care plan.
Documentation may need to be done using the 24-hour clock, or military time (Fig. 1-16).
Documentation may require the 24-hour clock, or military time (Fig. 1-16).
To change the hours to military time (between 1:00 p.m. and 11:59 p.m.) add 12 to the regular time.
To change from military time to regular time by subtracting 12. The minutes do not change.
Minimum Data Set (MDS)
The Minimum Data Set (MDS) is a detailed form that guides the assessment of residents.
Nurses must complete the MDS within 14 days of admission, annually, and every three months.
A new MDS must be done when there is any major change in the resident's condition.
NAs contribute to the MDS by reporting changes in residents and documenting accurately.
Incident Reports
An incident is an accident, problem, or unexpected event.
An incident report documents the incident and the response to it.
Incidents that should be reported include:
A resident falls
An NA or resident breaks or damages something
A mistake in care
A resident or family member makes sexual advances or remarks
Anything that makes an NA feel uncomfortable, threatened, or unsafe
An NA gets injured on the job
An NA is exposed to blood or body fluids
NAs must report any incident immediately to the charge nurse.
Guidelines for Incident Reporting:
Tell what happened, state the time, and describe the mental and physical condition of the person.
Describe the person's reaction to the incident.
State the facts and do not give opinions.
Do not document on the medical record that an incident report was completed.
Describe the action taken to give care.