Nursing Assistant in Long-Term Care Notes

## Long-Term Care vs. Other Healthcare Settings - Healthcare occurs in various settings with similar and unique tasks, each designed to meet specific patient needs. - Long-term care (LTC) is provided in LTC facilities, also known as skilled nursing facilities (SNFs), offering 24-hour skilled care for individuals with chronic illnesses or disabilities. - Skilled care is medically necessary, ordered by a doctor, and involves a treatment plan, which is essential for residents needing continuous medical attention. - LTC facilities are also known as skilled nursing facilities (SNFs), rehabilitation centers, or extended care facilities, providing a range of services from temporary rehabilitation to ongoing care. - Residents in LTC facilities may be disabled, elderly, or younger adults needing 24-hour care due to various health conditions. - Length of stay varies from short (days or months) for rehabilitation to longer than six months for chronic conditions. - Some residents have terminal illnesses, requiring end-of-life care, while others recover and return home after a period of skilled nursing. - Most residents have chronic conditions like physical disabilities, heart disease, or dementia, necessitating continuous and specialized care. - Residents reside in these facilities, making it their home for the duration of their stay, emphasizing the importance of creating a comfortable and supportive environment. - Residents have different diagnoses and require varying levels of care, leading to individualized care plans tailored to each resident's specific needs. ## Other Healthcare Settings - Home health care (home care): Provided in a person's home, generally for older, chronically ill individuals who wish to remain at home, offering personalized medical care and support services. - Assisted living facilities: Residences for people needing help with daily tasks but not 24-hour skilled care, providing a balance of independence and assistance. - Adult day services: Provide help and supervision during certain hours for people who need some assistance but are not seriously ill or disabled; also provides respite for caregivers, supporting both the individual and their family. - Acute care: 24-hour skilled care in hospitals and ambulatory surgical centers for short-term, immediate illnesses or injuries, focusing on rapid intervention and stabilization. - Subacute care: Given in hospitals or LTC facilities for those needing less care than acute but more than chronic illness; treatment continues until stabilization or completion, bridging the gap between intensive and long-term care. - Outpatient care: Short-term skilled care after treatments, procedures, or surgeries without an overnight stay, allowing patients to recover at home while receiving necessary medical support. - Rehabilitation: Care given by specialists (physical, occupational, speech therapists) to restore or improve function after illness or injury, aiming to enhance quality of life and independence. - Hospice care: Given in facilities or homes for people with six months or less to live, providing physical and emotional care and support for families, focusing on comfort and dignity in the final stages of life. ## Typical Long-Term Care Facility - LTC facilities provide 24-hour skilled nursing care, addressing a wide range of medical and personal needs. - They may offer assisted living, dementia care, or subacute care, with some offering specialized care such as ventilator management or wound care. - Personal care includes bathing, skin, nail, hair, and mouth care; assistance with walking, eating, dressing, transferring, and elimination, ensuring residents' hygiene and comfort are maintained. - Activities of daily living (ADLs) encompass these daily personal care tasks, highlighting the importance of supporting residents in maintaining their independence and dignity. - Common services include physical, occupational, and speech therapy; wound care; care of tubes (e.g., catheters); nutrition therapy; and management of chronic diseases (Alzheimer's, AIDS, diabetes, COPD, cancer, CHF), providing a comprehensive approach to health management. - Specialized care requires specially trained employees, emphasizing the need for ongoing education and expertise in specific medical areas. - Facilities can be owned by nonprofit or for-profit companies, influencing their financial priorities and approaches to care. ## Residents' Rights & Person-Centered and Trauma-Informed Care - LTC facilities promote meaningful environments with individualized care approaches, fostering a sense of community and well-being. - Person-centered care emphasizes individuality, recognizes capabilities, and promotes individual preferences, choices, dignity, and interests, ensuring care is tailored to each resident's unique needs and desires. - Respect for background, culture, language, beliefs, and traditions is crucial in providing culturally sensitive and respectful care. - An important goal of person-centered care is to improve each resident's quality of life, focusing on enhancing their overall happiness and fulfillment. - Trauma-informed care recognizes that people may have experienced trauma (abuse, neglect, violence, prison, combat, unstable home environments, poverty, discrimination, life-threatening illness, negative medical experiences), impacting their physical and emotional well-being. - Trauma-informed care seeks to consider each person's trauma, experiences, and preferences and provide a person-centered approach to care, promoting healing and a sense of security. ## Medicare and Medicaid - The Centers for Medicare & Medicaid Services (CMS) runs Medicare and Medicaid, overseeing the quality and standards of care in healthcare facilities. - Medicare: Federal health insurance program established in 1965 for people aged 65 or older and those with permanent kidney failure or certain disabilities. - Part A: Pays for care in a hospital, skilled nursing facility, home health agency, or hospice, covering essential inpatient services. - Part B: Pays for doctor services, other medical services, and equipment, supporting outpatient and preventive care. - Part C: Allows private health insurance companies to provide Medicare benefits, offering alternative coverage options. - Part D: Pays for medications prescribed for treatment, helping to manage prescription drug costs. - Medicare pays only for medically necessary care, requiring documentation and justification for services provided. - Medicaid: 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, varying by state regulations. - Medicare and Medicaid pay LTC facilities a fixed amount for services based on residents' needs upon admission and throughout their stay, influencing staffing levels and resource allocation. ## Nursing Assistant's Role - A nursing assistant (NA) performs assigned nursing tasks and provides personal care, working under the supervision of registered nurses or licensed practical nurses. - Common duties include bathing, assisting with elimination, assisting with range of motion exercises and ambulation, transferring residents, measuring vital signs, assisting with meals, helping residents dress and undress, giving backrubs, helping with mouth care, making and changing beds, and keeping residents' areas neat and clean, directly impacting residents' comfort and well-being. - Promoting independence and self-care is a critical part of the job, empowering residents to maintain their abilities and dignity. - NAs are not allowed to insert or remove tubes, give tube feedings, or change sterile dressings, with some states allowing medication administration after specialized training, highlighting the boundaries of their scope of practice. - Observing and reporting changes in a resident's condition is very important for early detection of health issues and timely intervention. - Noting and recording information is called charting or documenting, creating a legal record of care provided and residents' responses. - Nursing assistants are part of a healthcare team including doctors, nurses, social workers, therapists, dietitians, specialists, residents, and residents' families, emphasizing the importance of collaboration and communication. - Nursing assistants have different titles (nurse aide, certified nurse aide, patient care technician, certified nursing assistant), varying by state requirements, but their core responsibilities remain consistent. ## Responsibility for Residents - All residents are the responsibility of each NA, requiring vigilance and proactive care. - NAs receive assignments for specific residents but should assist any resident needing help, fostering teamwork and a supportive environment. ## Care Team and Chain of Command - The care team consists of healthcare professionals with a wide range of education and experience, working together to provide comprehensive care. - Members include: - Nursing Assistant (NA): Performs assigned tasks and assists with personal care; requires at least 75 hours of training and a competency evaluation. - Registered Nurse (RN): Coordinates, manages, and provides skilled nursing care; assigns tasks and supervises NAs; requires a two- to four-year nursing program and a national licensure examination. - Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN): Gives medications and treatments; requires one to two years of education and a national licensure examination. - Advanced Practice Registered Nurse (APRN): Registered nurse with postgraduate training; can make diagnoses and prescribe treatment. - Physician or Doctor (MD or DO): Diagnoses disease or disability and prescribes treatment and medication; requires a four-year medical school after a bachelor's degree. - Physician Assistant (PA): Diagnoses disease or disability, develops treatment plans, and prescribes medication under a doctor's supervision; requires a master's degree and a national licensure examination. - Physical Therapist (PT or DPT): Evaluates and develops treatment plans to increase movement, improve circulation, promote healing, reduce pain, prevent disability, and regain or maintain mobility; requires a doctoral degree and national licensure examinations. - Occupational Therapist (OT): Helps residents adapt to disabilities and perform ADLs using assistive devices; requires a master's or doctoral degree and a national licensure examination. - Speech-Language Pathologist (SLP): Identifies communication disorders, addresses recovery factors, and develops a plan of care; requires a master's degree and licensure or certification. - Registered Dietitian (RD or RDN): Assesses nutritional status and develops treatment plans to improve health and manage illness; requires a bachelor's or master's degree and a national licensure examination. - Medical Social Worker (MSW): Determines residents' needs and helps get them support services; requires a master's degree in social work. - Activities Director: Plans activities to help residents socialize and stay active; requires a bachelor's or associate's degree or qualifying work experience. - Resident and Resident's Family: Important members of the care team who help plan care, providing valuable insights and preferences. - The chain of command is the line of authority that ensures proper healthcare and protects employees and employers from liability, following a hierarchical structure. - Nursing assistants must understand their scope of practice to avoid performing tasks beyond their training and legal limits. - The care plan is individualized for each resident and includes tasks, services, treatments, frequency, and specific instructions, reflecting the resident's unique needs and goals. - Care planning involves input from the resident, family, and health professionals, ensuring a collaborative and person-centered approach. - NAs are responsible for making observations and reporting them to the nurse, facilitating timely and effective medical intervention. ## Policies, Procedures, and Professionalism - Facilities have policies (courses of action) and procedures (methods) that staff must follow, ensuring consistent and quality care. - Common policies: - Resident information must remain confidential to protect privacy and maintain trust. - The care plan must always be followed to ensure consistent and appropriate care. - NAs should not do tasks outside their job description to avoid legal and ethical issues. - NAs must report important events or changes in residents to a nurse for timely intervention. - NAs should not discuss their personal problems with residents or residents' families to maintain professional boundaries. - NAs should not take money or gifts from residents or their families to avoid conflicts of interest. - NAs must be on time for work and must be dependable to ensure adequate staffing and consistent care. - Professionalism includes appropriate dress, good communication, punctuality, task completion, and accurate reporting, contributing to a positive and efficient work environment. - A professional relationship with residents involves person-centered care, a positive attitude, following the care plan, maintaining confidentiality, and being polite, fostering trust and respect. - A professional relationship with an employer involves completing tasks efficiently, following policies and procedures, documenting and reporting accurately, reporting problems, asking questions when unsure, participating in education programs, and being a positive role model, contributing to a well-functioning healthcare team. - Nursing assistants must be: - Compassionate: Caring, concerned, empathetic, and understanding towards residents and their needs. - Honest: Truthful and trustworthy in all interactions and documentation. - Tactful: Showing sensitivity and appropriateness in communication. - Conscientious: Doing their best and being responsible in all tasks. - Dependable: Making and keeping commitments to ensure consistent care. - Patient: Not easily losing temper or acting annoyed, maintaining a calm and supportive demeanor. - Respectful: Valuing other people's individuality and treating everyone with dignity. - Unprejudiced: Giving equal quality care regardless of background or personal characteristics. - Proactive: Anticipating potential problems and needs to prevent issues and ensure residents' well-being. ## Legal and Ethical Behavior and Residents' Rights - Ethics are the knowledge of right and wrong; laws are rules set by the government, providing a framework for acceptable behavior. - Guidelines for legal and ethical behavior: - Be honest in all interactions and documentation. - Protect residents' privacy and confidentiality to maintain trust and respect. - Report abuse or suspected abuse to ensure residents' safety and well-being. - Follow the care plan and assignments to provide consistent and appropriate care. - Do not perform tasks outside your scope of practice to avoid legal and ethical issues. - Report observations and incidents to the nurse for timely intervention. - Document accurately and promptly to maintain a complete and reliable medical record. - Follow safety and infection prevention rules to protect residents and staff. - Do not accept gifts or tips to avoid conflicts of interest. - Do not get personally or sexually involved with residents or their families to maintain professional boundaries. - The Omnibus Budget Reconciliation Act (OBRA) of 1987 sets minimum standards of care and training for nursing assistants (at least 75 hours of training), aiming to improve the quality of care in nursing homes. - OBRA requires competency evaluation, minimum in-service education (12 hours per year), state registry, and standards for instructors, ensuring ongoing professional development and accountability. - OBRA includes resident assessment requirements and made changes in the survey process to enhance care planning and facility oversight. - Residents' Rights: - Quality of life: Best care available with dignity, choice, and independence, promoting overall well-being and satisfaction. - Services and activities to maintain a high level of wellness: Correct care, care plan development, and prevention of decline, focusing on maintaining or improving residents' physical and mental health. - Right to be fully informed about rights and services: Disclosure of services, fees, legal rights, contact information for state agencies, and survey results, empowering residents to make informed decisions. - Right to participate in their own care: Involvement in planning treatment, care, and discharge; informed consent; right to refuse or discontinue treatment, promoting autonomy and self-determination. - Right to make independent choices: Decisions about doctors, care, treatments, personal activities, and participation in community activities, fostering independence and personal expression. - Right to privacy and confidentiality: Private communication and confidentiality regarding medical and personal information, protecting residents' dignity and personal information. - Right to dignity, respect, and freedom: Respectful treatment without abuse, mistreatment, or neglect, ensuring a safe and supportive environment. - Right to security of possessions: Protection of personal possessions from loss or theft; management of own finances, safeguarding residents' assets and personal belongings. - Rights during transfers and discharges: Informed consent for location changes, justification for transfer/discharge, and effective discharge planning, ensuring a smooth and well-coordinated transition. - Right to complain: Ability to voice grievances without fear, promoting open communication and problem-solving. - Right to visits: Unrestricted visits from doctors, family, friends, and other representatives, fostering social connections and support. - Rights with regard to social services: Access to counseling, problem-solving assistance, and legal/financial guidance, addressing residents' psychosocial needs. - Guidelines for protecting residents' rights: - Never abuse a resident to ensure their safety and well-being. - Call the resident by their preferred name to show respect and acknowledge their identity. - Involve residents in planning to promote autonomy and self-determination. - Explain procedures before performing them to reduce anxiety and promote cooperation. - Do not unnecessarily expose a resident to protect their privacy and dignity. - Respect a resident's refusal of care to honor their autonomy and choices. - Be truthful when documenting care to maintain accurate and reliable records. - Do not gossip about residents to protect their confidentiality and reputation. - Knock before entering a resident's room to respect their privacy and personal space. - Do not accept gifts or money to avoid conflicts of interest. - Do not open a resident's mail or look through their belongings to protect their privacy and security. - Respect residents' personal possessions to honor their dignity and autonomy. - Report observations about a resident's condition or care to facilitate timely and effective medical intervention. - Help resolve disputes to promote a harmonious and supportive environment. ## Maintaining Boundaries & Abuse and Neglect - Boundaries are limits within relationships that support a healthy resident-staff dynamic, preventing exploitation and maintaining professionalism. Follow facility rules and the care plan’s instructions to ensure appropriate care. - Abuse is purposeful mistreatment, including: - Physical abuse: Causes harm to a person's body through hitting, slapping, or other forms of physical violence. - Psychological abuse: Emotional harm through threats, intimidation, or isolation, causing distress and anxiety. - Verbal abuse: Insulting or threatening language that undermines a person's self-esteem and dignity. - Sexual abuse: Nonconsensual sexual contact, violating a person's bodily autonomy and boundaries. - Financial abuse: Improper use of a person's money or property, exploiting their vulnerability for personal gain. - Assault: Threat to harm a person, creating fear and apprehension. - Battery: Intentional touching without consent, violating a person's personal space and boundaries. - Domestic violence: Abuse by spouses, partners, or family members, occurring within a household setting. - False imprisonment: Unlawful restraint of movement, depriving a person of their freedom and autonomy. - Involuntary seclusion: Separation from others against their will, causing emotional distress and isolation. - Workplace violence: Abuse of staff by others, creating a hostile and unsafe work environment. - Sexual harassment: Unwelcome sexual advances, creating a hostile and uncomfortable environment. - Substance abuse: Harmful use of drugs or alcohol, impairing judgment and behavior. - Neglect is the failure to provide needed care, potentially leading to physical or emotional harm. - Negligence is actions or failure to act that results in unintended injury, often due to carelessness or lack of attention. - Malpractice occurs when injury results from professional misconduct, violating the standards of care. - Nursing assistants must report suspected abuse to the nurse in charge immediately to protect residents and uphold ethical standards. - Signs of abuse include suspicious injuries, yelling obscenities, fear, poor self-control, and withdrawal, indicating potential mistreatment. - Signs of neglect include pressure injuries, unclean body, unanswered call lights, and unmet needs, reflecting inadequate care and attention.
Ombudsman - An ombudsman is a legal advocate for residents in long-term care facilities, protecting their rights and promoting their well-being. ## Confidentiality and HIPAA - To respect confidentiality means to keep private things private, protecting residents' personal information and dignity. - The Health Insurance Portability and Accountability Act (HIPAA) of 1996 protects health information, ensuring privacy and security. - Protected health information (PHI) includes information that can identify a person, such as name, address, medical history, and social security number. - Guidelines for protecting privacy: - Ensure private areas for reading/listening to messages to protect residents' personal communications. - Verify with whom you are speaking on the phone before sharing information to prevent unauthorized disclosure. - Do not talk about residents in public to protect their confidentiality and reputation. - Use confidential rooms for reports to ensure private information is not overheard. - Be careful with greetings to family members or former residents in public to avoid unintentionally revealing personal information. - Do not bring family or friends to meet residents to protect their privacy and prevent potential conflicts of interest. - Secure computer screens and log out when finished to prevent unauthorized access to electronic health records. - Do not give confidential information in emails unless properly encrypted to protect against interception. - Do not share resident information on social networking sites to avoid privacy breaches and potential harm. - Verify fax numbers before sending documents to ensure they reach the intended recipient. - Store, file, or shred documents according to policy to maintain confidentiality and comply with regulations. - Penalties for violating HIPAA include fines and prison sentences, highlighting the seriousness of privacy breaches. ## Legal Aspects of the Resident's Medical Record - The medical record is a legal document that provides a comprehensive account of a resident's health status and care. - Documenting care is essential for clear communication, legal protection, and up-to-date records, ensuring continuity and accountability. - Guidelines for careful documentation: - Document care immediately after giving it to ensure accuracy and completeness. - Be brief, clear, and factual in your notes to provide a concise and reliable record. - Use black ink and write neatly to ensure legibility and professionalism. - Draw one line through mistakes, initial, and date to correct errors without obscuring the original information. - Sign your full name and title with the date to authenticate your documentation. - Document as specified in the care plan to maintain consistency and adherence to the prescribed care. - Use the 24-hour clock (military time) to avoid ambiguity and ensure accurate timekeeping. ## Minimum Data Set (MDS) - The Minimum Data Set (MDS) is a detailed assessment form for residents used to gather comprehensive information about their physical, mental, and psychosocial well-being. - Nurses complete the MDS within 14 days of admission and annually, with reviews every three months, to track changes in residents' condition and update their care plans accordingly. - NAs contribute by reporting changes and documenting accurately, providing valuable insights into residents' daily experiences and needs. ## Incident Reports - An incident is an unexpected event during care that may have adverse effects on a resident's health or well-being. - Incidents include mistakes in care, falls, accusations, and employee injuries, requiring thorough documentation and investigation. - Incident reports document the incident and response, providing a record of what happened and the actions taken to address it. - Guidelines for incident reporting: - Tell what happened, including the time and condition of the person, to provide a clear and factual account of the event. - Describe the person's reaction to document the impact of the incident. - State facts, not opinions, to maintain objectivity and avoid bias. - Do not document on the medical record that an incident report was completed to protect the confidentiality of the report. - Describe the action taken to give care to demonstrate the response to the incident.