ROLE OF RN IN ASSISTED LIVING OLTC

Transcription

1 OLTC Initial RN Assessment upon admission Must be completed within the first 30 days of admission. We try to do the RN assessments within 7 days of admission so that we have a baseline. The LPNs do an initial assessment the admit day to ensure we have admission bases covered. Form: RN Assessment; LPN Initial Assessment OLTC

2 A Health Care Service Plan Must be done on an order received for something only a nurse can do, i.e., wound care. The RN must complete and sign the Medication Administration HCSP for residents who require medication administration and any HCSP the resident requires. A quarterly review must be done until it is completed or DC d. Form: Quarterly Review Form 2

3 QUARTERLY RN REASSESSMENTS HCSP S Medication Administration is required on the Medicaid Residents whom the DHS RN marks as Med Administer, even if they do their own meds. HCSP s are required on Medicaid residents. The POC the DHS nurse completes is considered the start of services provided. This is a change from previous years. The RN must also sign the Quarterly Medicaid Form Form: Quarterly RN Reassessments; Medication Assessment; Medication HCSP OLTC

4 ANNUAL RN ASSESSMENT ON ALL RESIDENTS If there has been no change the RN can so indicate, sign and date. Form: RN Assessment (There has been some disagreement with Long- Term Care that they have to re-do the RN Assessment annually.) Have not heard from OLTC Concerning this issue. OLTC 702.d.1 4

5 RN Assessment with the Change of Condition Documentation required on any change that is not resolved within 14 days. Form: Change of Condition OLTC 702.d.1 5

6 Service Functional Assessment Completed by Administrator/Assistant or RN. Determine if resident has direct care service needs. Evaluation form must indicate if resident DOES OR DOES NOT have direct care service needs. Direct Care Service Plan is completed on everyone upon admission and annually. Must document participation of resident or POA. DCSP changes with any change of services. Form: Service Functional Assessment; DCSP OLTC 701 6

7 Ancillary Care Plan (RN Review and Sign Off) Home Health Hospice Does not require quarterly review Any outside agency service Remove from chart when service is DC d Form: Ancillary Care Plan OLTC

8 I & A Review: Required by OLTC for the RN to review all I&As within 5 days of occurrence. They must be reviewed within 5 days by the RN and Administrator. You must note the DCSP was reviewed and if any changes were made, date and sign. The I&As must be checked for any missing areas or items and turned into QAPI and inservice the staff on completion of the I&As Form: Universal Occurrence OLTC

9 QAPI REVIEW: Name, date, location, time, injury Who completed Physician notified by 11:00 a.m. next day Family notified by LPN/RN/Administrator/Owner Vital signs recorded Notes made and turned into QAPI Coordinator OTLC 506 Check with Administrator/Director as to who the QAPI Coordinator is in your community 9

10 RN Duties Supervise LPN/Resident Assistants RN on Call 24/7 OLTC b Training and In-Service Hands-on training after making resident rounds Develop Nursing Procedures specific to your company. We use the Lippincott Manual of Nursing Practice. OLTC c 1) Develops new ones as needed 2) Reviews Annually Admission evaluates inquiries to determine eligibility for ALF II Update HCSP Quarterly, or as Condition/Service changes 10

11 RN Duties Continued Required training at Orientation for CNAs/Direct Care; Aging process training Disability sensitivity training Identified In-services that are needed to improve quality care. Medication Tech training Dementia training Oxygen Assistance Elopement Training Be a part of the Orientation Program of new employees OLTC b., c. 11

12 RN Duties Continued LPN Training PRN Refusal Documentation Daily Census Report 24/48 Follow-up on I&As What to Report 12

13 RN Duties Continued Sits in on interviews, if schedule permits Reviews/approves Nursing Department schedule Completes annual evaluations with Community Director for LPN/RA s Assists with the 90 day evaluation with HR or Administrator for Nursing 13

14 RN Duties Continued Committees (Member) QAPI: Community plan, develop, implement nursing QAPI plan Grievance employee/resident/family Resident concerns Care Plan meetings Forms Committee Admissions 14

15 RN Duties Continued Review/update duty sheets Round on all ill residents when in community and document-especially anyone with skin issues Develop standards of practice for: Falls Pressure Ulcers Oral care/nail care/hair/shaving 15

16 RN Duties Continued Training Programs Resident Assistant Career Ladder Program Mentoring Program Team Leader 16

17 RN Duties Continued On-Call as scheduled coordinate with Administrator for call schedule. Develop About what RN is to be notified Reasons to call: 1) Death 2) Fall with injury 3) Family issue schedule Care Plan Mtg Liaison with Medical Director, outside Agencies Develop standard protocols 17

18 QUESTIONS?? 18