RN CONSULTATION. KEY TERMS: Assessment Basic tasks Consultation Home health services PRN Written parameters OBJECTIVES:

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1 RN CONSULTATION The purpose of this section is to assist the learner in understanding the role of a registered nurse (RN) consultant and when to seek RN consultation. KEY TERMS: Assessment Basic tasks Consultation Home health services PRN Written parameters OBJECTIVES: After completing this section the learner will be able to: Define RN consultation. Describe when to involve the RN for consultation. Understand what PRN medications are and why written parameters are required. Describe when home health services may be needed by the resident.

2 RN CONSULTATION INTRODUCTION Many residents living in the adult foster home (AFH) setting have health problems and chronic health care needs that may require consultation with a registered nurse (RN). DHS outlines in OAR , Standards and Practices for Care and Services, when the AFH must seek consultation from an RN. DHS expects the AFH provider to understand when to access RN consultation to meet the care needs of the resident. Information gathered during the resident s health care screening is the first opportunity for the AFH provider to determine if an RN consultation is needed. The initial assessment of the new resident will also provide information on their health care needs and the potential need to seek consultation from an RN. Keep in mind that residents residing in your home may develop new care needs that will require the involvement of an RN. This section discusses what RN consultation is, when it s needed, and the RN consultants role with PRN (as needed) and psychotropic medications. Additionally, information will be provided on how to verify an RN s license, when to request consultation from other qualified health care professionals and when to consider requesting a referral for home health services. Ensuring Quality Care RN consultation is intended to be used only when the resident has a known health condition and is not a substitution for seeking advice or medical care from the resident s primary care practitioner. RN consultation cannot be used for new conditions that have not been evaluated by the resident s primary care practitioner. 1

3 RN CONSULTATION RN consultation means the RN visits the AFH to assess the resident s existing physical, medical, emotional and functional health care needs. The RN uses the information gathered during the assessment of the resident to determine the resident s and caregivers teaching needs. Reasons to involve the RN in a resident s care: Complex health problems or multiple diagnoses; Medical needs you or your staff do not understand; Nutritional problems; Skin breakdown; Challenging behaviors; Psychoactive medications; Physical restraints; Activities of daily living that are unusual or about which you or your staff need more information or training; Multiple and confusing medication orders; Unclear orders for pain medications. The RN may determine certain tasks that need to be performed for the resident. You may have already identified these tasks since they are frequently ordered by the physician. Some examples of health support tasks that an RN may need to teach you and your caregivers include: Blood pressure checks; Taking a pulse; Enemas; Range of motion; 2

4 Temperatures; Inserting suppositories; Transfer techniques; Special diets; Ambulation after an injury or surgery; Emptying drainage bags; Oxygen for self-directed residents. An RN consultant may also need to help you review your medication administration system. AFH rules require the AFH provider to have a safe medication administration system. However, if there have been multiple medication errors, it may be appropriate to seek advice from an RN about what you need to change. Many of the tasks you will regularly perform may require minimal training from the RN. However, there are some tasks of nursing that will require an RN to delegate the task before the caregiver can perform the task. RN delegation is discussed in Ensuring Quality Care Another important role of the RN consultant is to provide information and teaching about the residents unique health support needs. Many residents have multiple chronic health care needs that may require a deeper understanding of how to support them. Certain chronic health conditions such as Parkinson s disease have specific, complex health support needs. For example, it is generally acceptable to give a medication within 30 minutes of the scheduled time. However, many medications used for Parkinson s disease must be given within 15 minutes of the scheduled time. Being more then 15 minutes late can mean hours of suffering for the resident with Parkinson s disease. Some of these drugs are used for other conditions, but timing is not as sensitive as it is with Parkinson s disease. Additionally, certain foods with medications used to treat the symptoms of Parkinson s disease cannot be taken together. Using an RN consultant is critical in assuring you are able to provide the appropriate health support for the resident living with complex medical health issues. 3

5 detail in the section titled RN delegation for lay caregivers. Some examples of nursing tasks that require the RN to delegate are: Subcutaneous injections such as insulin; Food, fluid and/or medications through any feeding tube; Suctioning; and Straight catheterization. PRN MEDICATIONS Some medications, such as medications used for pain, are written as PRN, meaning the medication is given as needed. AFH rules require that all PRN medications have specific parameters indicating what the medication is for and specifically when, how much and how often the medication may be administered. It is preferable for the prescribing practitioner to write the parameters when ordering any PRN medication. It is also helpful to ask your pharmacist to request this information when accepting a prescription order over the phone. If a PRN medication does not include specific written parameters, you may ask the RN to assess the resident and write the parameters. The RN will need to assess the resident s condition treated by the prescribed medication and may need to consult with the prescribing practitioner before completing written parameters. The parameters should be recorded on the medication record (MAR). You may also wish to use form SDS 812 that allows more in-depth instruction to be given in the parameters. Any caregiver dispensing medications for that specific resident must follow the instructions. If you or one of your caregivers does not have a clear understanding of the instructions, have the RN, pharmacist or prescribing practitioner explain in more detail. 4

6 PSYCHOACTIVE MEDICATIONS The AFH laws and rules discourage the use of psychoactive medications for those residents who do not have clear long-term psychiatric diagnoses. These medications have been used frequently for the elderly to affect their behavior or cognitive processes or to reduce anxiety. Most often this can be done more safely and effectively without the use of medications by learning how to work with the behaviors. This is called using alternative measures. The RN consultant can be asked to assess the resident and help determine the cause of the behavioral problems (often caused by medications or infections). The RN may recommend additional assessment by a physician, nurse practitioner or mental health therapist to assist you in finding alternative measures to work with the behaviors. You will find more specifics on psychoactive medications in the Medication management section in Chapter 3. Additional information regarding behaviors can be found in Chapter 5, Working with challenging behavior. The psychoactive medications that are of concern include the following: Anti-psychotic Sedatives Hypnotics If a potential resident is on any medication in one of the above classifications, find out who prescribed it and when it was prescribed. Sometimes a person is prescribed one of these very potent medications in the hospital due to an episode of sleeplessness, anxiety or a behavior problem. The medication is frequently no longer needed or is not appropriate in another care setting. You should obtain a complete assessment from the resident s primary health care practitioner or mental health specialist, to determine if the medication is still needed. Ensuring Quality Care Anti-anxiety medication 5

7 PHYSICAL RESTRAINTS A physical restraint means any manual method or physical or mechanical device, material or equipment attached to or near a resident s body that prevents the resident from moving easily. A restraint restricts the resident from normal freedom of movement or normal access to the body. The use of physical restraints is strongly discouraged in the AFH setting. Here are some examples of physical restraints: Leg restraints Hand mitts Soft vests Wrist ties Soft ties Lap trays Wheelchair safety bars Geri-chairs Any chair that prevents a person from rising Bedrails (side rails) unless requested by the resident to assist in turning, transfer or mobility Restraints have become a nearly obsolete way of handling behavioral problems and/or safety concerns. Research has determined there is actually a higher incidence of serious injury, even death, with the use of physical restraints. AFH rules do not allow the use of restraints without a thorough assessment of the behavioral or safety concerns and a trial of alternative measures to alleviate the problem. There are much safer ways to protect the resident. 6 The use of restraints has proven to be more dangerous than allowing a resident to move around as desired, even if there is potential for falling. A resident intent on getting up will struggle to do so even if restrained.

8 Restraints tend to further aggravate a resident and increase the behavior you want to avoid. A restrained person will often tug and pull and try to climb over anything blocking the way. For example, because the resident has to climb over a rail to get out of bed, the fall is higher and more damaging than if the fall were from the mattress. Tie-on restraints can choke or hang a resident who gets up and falls. Refer to Chapter 5, Working with challenging behaviors, for additional information. Use of any restraint requires that a doctor, nurse practitioner, RN, Christian Science practitioner, mental health clinician, physical therapist or occupational therapist has assessed the problem and the potential need for the restraint. Restraints cannot be used for the caregiver s convenience. There has to be proof that the restraint is required to treat the resident s medical condition or to maximize the resident s physical functioning. In order to use a restraint, a physician s or nurse practitioner s order must be obtained, and the resident must agree to the restraint. Documentation must also indicate that other methods were tried. Note: If a resident is unable to say he or she does not want a restraint, struggling against the restraint indicates the person does not agree to the restraint. Daytime restraints must be released at least every two hours for ten minutes. Nighttime restraints are especially discouraged. If used, they must allow freedom of movement in bed and require frequent monitoring. Ensuring Quality Care If the qualified health professional determines a restraint is needed, it will be used as little as possible and allow as much movement as possible. The assessment must include written procedural guidance describing interventions to try before using the restraint. This guidance must also include the dangers related to using the restraint and detail on how to correctly use the restraint. 7

9 SEEKING AN RN CONSULTANT If a resident requires an RN consultation, rules specify the AFH must seek it regardless of the payment source. If a resident is being newly admitted or a current resident's care needs change and you are not sure about the care or you know the resident requires a special nursing task you must seek consultation with a RN. Your challenge is to locate an RN who is knowledgeable about AFH rules, community-based care and residents' rights issues. If during the pre-admission screening you determine there is a need for RN consultation you must make arrangements for the RN consultation before admission. Additionally, the RN must be notified prior to admission to make arrangements for the RN to be present upon admission to address RN Delegation needs. See Delegation for Lay Caregivers for more information. Private-pay residents need to be aware of the possible need for RN consultation before they enter your home. Payment for the serve can be addressed in the private-pay contract. Payment for Medicaid residents is included in your monthly Medicaid payments. There are several options for seeking a RN: HOME HEATLH Residents admitted directly from a nursing facility or hospital with a newly diagnosed condition may require home health services for a short period of time. Home health services can be attached to a local hospital or be an independent agency. Services available through a home health agency include RN consultation, assessment, direct nursing care, delegation, physical therapy, occupational therapy, speech therapy, social work/counseling and bath aide. 1 The home health RN can provide direct hands-on care1to a resident. The home health agency works under a physician's order and generally performs tasks paid for by Medicare, Medicaid or other insurance. An example of a common task provided by a home health agency is wound management. Wound management cannot be delegated.

10 Private Contract You may want to privately contract with an RN to be available for consultations including medication management, monitoring, assessing and RN delegation. The RN could visit regularly and provide technical assistance and interventions on an ongoing basis or be available on-call as you determine necessary. Talk with other Adult Foster Home providers in your area, your neighbors, or local churches for RN consultant recommendations. Community Health Support Program (CHSP) Formally known as the Contract RN program: The Community Health Support Program (CHSP) allows a RN the ability to provide a limited set of services to individuals served by Seniors and People with Disabilities with chronic health care needs living at home or in a foster home setting. The primary role of a RN participating in CHSP is to provide training and education for the individual and their care givers regarding their health support needs and RN Delegation for tasks of nursing. CHSP program does not provide direct care services. See Community Health Support Program for more information. Verifying a RN's License It is critical that any RN you use has a current and valid Oregon license. The best way to assure the RN you are considering has a valid license is to verify their license through the Oregon State Board of Nursing (OSBN). The OSBN has an online service to assist with license verification. Go to Below is a screen print of the page where you will enter the RN's information. In most cases you will only need the person's first and last name. However, if the RN has a common last name, you will need to ask for their RN License number to assure you accessed the correct person. Keep a copy of the verification for your records. Ensuring Quality Care One of the most common reasons for an invalid RN license is failure to renew it. If a RN works in your AFH without a valid license, the documentation and any delegation will not be valid. Revised April 2014

11 Once you enter the RNs license number, if known, or the individuals first and last name and select search another screen with a list of all the RNs with the same name will appear.

12 Once the information is entered you will see a list of all the RNs with the first and last name you entered. Select the link with proper license number. Ensuring Quality Care After you select the correct record the following page will be displayed giving you the information you need to determine the RN has a valid unrestricted license.

13 The Verification Details page for the RN selected lists the date range the RNs license is good for and if there have been any discipline by the OSBN.

14 Oregon Department of Human Services This document can be provided upon request in an alternate format for individuals with disabilities. To request this publication in another format, contact the Publications and Design Section at , 711 for TTY, or

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