NORTH AMERICAN NORTH AMERICAN HEALTHCAREHEALTHCARE

UPDATE OF NURSING SERVICESUPDATE OF NURSING SERVICES

POLICYPOLICY

Facility through nursing & other services Facility through nursing & other services ensures that resident reaches his/her highest ensures that resident reaches his/her highest level of functioning.level of functioning.

GoalsGoals Recognize the limits of the diseaseRecognize the limits of the disease Normal aging processNormal aging process Resident’s right to treatment/refusal of:Resident’s right to treatment/refusal of:

• TreatmentTreatment

• Resident safetyResident safety

Skilled care and rehabilitation/restorative Skilled care and rehabilitation/restorative services are provided based on:services are provided based on: Strength & needs;Strength & needs; Has a treatment plan directed to increasing Has a treatment plan directed to increasing

resident’s improvementresident’s improvement Prevention of accidents and Prevention of accidents and maintenance of a maintenance of a

safe environmentsafe environment

COMPREHENSIVE FUNCTIONAL COMPREHENSIVE FUNCTIONAL ASSESSMENT (MDS)ASSESSMENT (MDS)

Facility shall complete a MDS which Facility shall complete a MDS which describes:describes: Capability to perform daily life functions;Capability to perform daily life functions; Significant impairments in functional capacity;Significant impairments in functional capacity; Ongoing assessment of resident’s health and Ongoing assessment of resident’s health and

psychosocial status and changes in condition;psychosocial status and changes in condition; Safety.Safety.

CARE PLANCARE PLAN

Shall be based on:Shall be based on: Initial comprehensive assessment;Initial comprehensive assessment; Interdisciplinary Team’s decision;Interdisciplinary Team’s decision; Interim conditions that require care and treatment Interim conditions that require care and treatment

services and unrelated risks.services and unrelated risks.

IN-SERVICE EDUCATIONIN-SERVICE EDUCATION

Continuing in-service education program:Continuing in-service education program: Conducted for all nursing personnelConducted for all nursing personnel Thorough job orientation for new personnelThorough job orientation for new personnel Skill training for non-professional personnel shall Skill training for non-professional personnel shall

begin at the time of orientationbegin at the time of orientation Also, refer to Nursing Assistant ProgramAlso, refer to Nursing Assistant Program

IN-SERVICE EDUCATION IN-SERVICE EDUCATION -2-2

Planned in-service programs:Planned in-service programs: Conducted regularly;Conducted regularly; Documented in writing (content, instructor, Documented in writing (content, instructor,

teaching aides employed, attendance)teaching aides employed, attendance) Include:Include:

• Demonstration;Demonstration;

• Practice;Practice;

• Supervision.Supervision.

IN-SERVICE EDUCATION IN-SERVICE EDUCATION -3-3

OrientationOrientation shall include but shall not be shall include but shall not be limited to:limited to: Emergency procedures;Emergency procedures; Residents’ rights;Residents’ rights; Skills required;Skills required; Protection of health information (HIPAA);Protection of health information (HIPAA); Abuse prevention/reporting;Abuse prevention/reporting; Sanction policies/procedures (HIPAA);Sanction policies/procedures (HIPAA); Physician reporting and Resident Safety Plan.Physician reporting and Resident Safety Plan.

UNUSUAL OCCURRENCE(S) - UNUSUAL OCCURRENCE(S) - REPORTINGREPORTING

Nursing to notify the attending physician of Nursing to notify the attending physician of unusual occurrences that affect or potentially unusual occurrences that affect or potentially affect the care and services to residents.affect the care and services to residents. Changes in condition;Changes in condition; Safety reportable eventsSafety reportable events;; Medication errors;Medication errors; Need to alter treatment significantly;Need to alter treatment significantly; Other significant resident events;Other significant resident events; Any epidemic outbreaks;Any epidemic outbreaks; And others (see Admin #7005).And others (see Admin #7005).

RESIDENT SAFETY RESIDENT SAFETY (See Safety Plan)(See Safety Plan)

During care and services, all staffs shall During care and services, all staffs shall follow the infection control system policies & follow the infection control system policies & proceduresprocedures Use proper hand hygiene programs;Use proper hand hygiene programs; Reduce suffering from preventable events;Reduce suffering from preventable events; Report events to the Quality Assurance Report events to the Quality Assurance

Committee via Infection Control / Resident Safety Committee via Infection Control / Resident Safety Review.Review.

RESIDENT SAFETY RESIDENT SAFETY (See Safety Plan) (See Safety Plan) -2-2

Resident Safety ProgramResident Safety Program ForemostForemost Staffs are trained report & monitor unsafe Staffs are trained report & monitor unsafe

conditions;conditions; Resident events that might affect resident safetyResident events that might affect resident safety

• Observing urine outputObserving urine output• Site of tubes such as G-tubes;Site of tubes such as G-tubes;• Patient safety of peripheral devicesPatient safety of peripheral devices• Wheelchairs and any other patient related equipmentWheelchairs and any other patient related equipment• Pumps;Pumps;• Appropriate positioning of healthcare tubesAppropriate positioning of healthcare tubes

RESIDENT SAFETY RESIDENT SAFETY (See Safety Plan) (See Safety Plan) -3-3

Resident Safety ProgramResident Safety Program Resident events that might affect resident safety Resident events that might affect resident safety

(cont.)(cont.)• Resident protectionsResident protections

• Care management environmental and criminal eventsCare management environmental and criminal events

ASSESSMENT AT DISCHARGEASSESSMENT AT DISCHARGE

Discharge information:Discharge information: Completed in conjunction with ancillary services Completed in conjunction with ancillary services

such as social services and activitiessuch as social services and activities Provide sufficient information to ensure continuity Provide sufficient information to ensure continuity

of careof care POLST form:POLST form:

Completed:Completed:• At admissionAt admission• During stayDuring stay• At dischargeAt discharge

Original form shall be sent with the resident.Original form shall be sent with the resident.

ASSESSMENT ON TRANSFER ASSESSMENT ON TRANSFER TO ACUTE HOSPITALTO ACUTE HOSPITAL

Resident is sent to an acute hospital:Resident is sent to an acute hospital: Final nursing note shall include clinical Final nursing note shall include clinical

documentation that describes:documentation that describes:• AssessmentAssessment

• Care and services providedCare and services provided

• Relevant dates and timesRelevant dates and times Interfacility Transfer RecordInterfacility Transfer Record

• Notations of any copies from the health record that Notations of any copies from the health record that were sent with the residentwere sent with the resident

• POLST form shall be sent with the resident if one is in POLST form shall be sent with the resident if one is in effecteffect