Thunderhawk Policy and Procedure Manual · Thunderhawk Management & Consulting, LLC page 1 Thunderhawk Policy and Procedure Manual When using this manual, please consider the following

Thunderhawk Management & Consulting, LLC page 1

Thunderhawk Policy and

Procedure Manual

When using this manual, please consider the following important points:

1. The policies and procedures outlined in the manual will never supersede

current regulation. To the best of our knowledge, these guidelines reflect

current regulation; nevertheless, they cannot be considered universal

recommendations. For individual application, all recommendations must

be considered in light of the resident’s condition. The authors and

publishers disclaim responsibility for any adverse effects resulting directly

or indirectly from the suggested procedures, from any undetected errors,

or from the reader’s misunderstanding of the text or video content.

2. Regulations and interpretations will change and it is your responsibility to

ensure that the Vantage Pointe Village or residential care community is

operated under the guidelines outlined in current regulation. Review

regulations, policy, procedures and instructions to ensure compatibility

with the regulations your community is obligated to abide by.

3. The guidelines outlined in this manual will never supersede a state

regulatory agency’s directive, physician order, or direction from a licensed

medical professional.


4. Hands-on resident care of any kind should always be in accordance with

physician orders. The interventions in this manual are not intended to be

personalized plans of care.

Copyright © 2009 by Thunderhawk Management & Consulting, LLC

All rights reserved. Permission is granted to photocopy written materials,

certificates and quizzes for internal use within the purchasing organization.

Otherwise this publication may not be reproduced, stored in a retrieval system or

transmitted in any form or by any means, electronic, mechanical, photocopying,

recording or otherwise, without prior written permission from the publisher.

Table of Contents

General Policies ............................................................................... 8 Personal Property/Theft and Loss............................................................................................... 9

Abuse, Fraud, and Wrongdoing ................................................................................................ 12

Personal Care Attendants ......................................................................................................... 14

Home Health Agencies ............................................................................................................. 15

Motorized Mobility Devices ....................................................................................................... 16

Resident Transportation........................................................................................................... 17

Resident Independent Departure Assessment ...................................................................... 18

Sign-In/Sign-Out....................................................................................................................... 19

Firearms................................................................................................................................... 20

Personal Rights ........................................................................................................................ 21

Dignity...................................................................................................................................... 23

Corporal Punishment and Restraints ........................................................................................ 24

Complaints................................................................................................................................ 25


Staffing ........................................................................................... 26 Staffing Introduction .................................................................................................................. 27

Staff Training ............................................................................................................................ 28

Job Description: Executive Director........................................................................................ 30

Job Description: Assistant Executive Director............................................................................ 31

Job Description: Resident Care Coordinator ............................................................................ 33

Job Description: Medication Aide .............................................................................................. 35

Job

Personal Assistant…………………………………………………………………………………37

Volunteers........................................................................................................................... 39

Admissions and Move-In.............................................................. 41 Resident Pre-Admission Appraisal ........................................................................................... 42

Allowable Health Conditions..................................................................................................... 44

Day of Admission/Move-In........................................................................................................ 46

Change in Condition................................................................................................................. 47

Ongoing Resident Appraisals.................................................................................................. 50

Activity Assessments ............................................................................................................... 52

Admission Agreements ............................................................................................................ 53

Service Plans ........................................................................................................................... 54

Resident Care Conference ...................................................................................................... 56

Move-Out .................................................................................................................................. 59

Resident Care ................................................................................. 60 Basic Care Services .................................................................................................................. 61

Use of Assistive Devices and Ambulatory Aids ........................................................................ 64

Hygiene and Grooming ............................................................................................................. 65

Dressing ................................................................................................................................... 66

Sleep and Rest ......................................................................................................................... 67

Incontinence............................................................................................................................. 69

Nutrition and Weights ................................................................................................................ 71

Podiatry and Nail Care.............................................................................................................. 72

Personal Assistant Daily Schedule ........................................................................................... 73

Sexual Expression.................................................................................................................... 77

Medication Management ............................................................... 78 Medication Storage ................................................................................................................... 79

Medication Records .................................................................................................................. 80


Telephone Orders ..................................................................................................................... 81

Medication Labels ..................................................................................................................... 82

Resident Arrives with a Medication ........................................................................................... 83

Medication Refills ..................................................................................................................... 84

Medications are Permanently Discontinued .............................................................................. 85

Hold Orders .............................................................................................................................. 86

Expired Medications................................................................................................................. 87

Medications Left Behind by a Resident ..................................................................................... 88

Medication Refusal and/or Missed Doses ................................................................................. 89

Crushing Medications ............................................................................................................... 90

Transferring Medications for Home Visits and Outings ............................................................. 91

Sample Medications ................................................................................................................. 92

Use of Emergency Medications ................................................................................................ 93

Injections .................................................................................................................................. 94

Over-the-Counter (OTC) Medications ....................................................................................... 96

Psychotropic Medications ......................................................................................................... 97 Warfarin and Other Anticoagulants ........................................................................................... 98

Narcotics, Controlled Substances, and Preventing Drug Diversion ........................................ 99

Emergencies and Medical Needs ................................................

101 Physician and Other Medical Appointments ........................................................................... 102

Labs and Outside Medical Services ........................................................................................ 103

Licensure of Nursing Personnel .............................................................................................. 104

Medical Emergencies ............................................................................................................. 105

Psychiatric Emergencies........................................................................................................ 108

Falls ........................................................................................................................................ 109

Death of a Resident ................................................................................................................ 110

Elopement/Missing Resident.................................................................................................. 112

Advance Directives................................................................................................................. 115

Documentation and Forms........................................................ 117 Confidentiality ......................................................................................................................... 118

Narrative Charting Entries ....................................................................................................... 119

Incident Reports ..................................................................................................................... 120

Procedure ............................................................................................................................... 120

Abbreviations .......................................................................................................................... 121

Approved Abbreviations ......................................................................................................... 122


Terminology

Various terms related to resident care are used throughout this manual. While

most of these terms are commonly accepted in the industry, there is some

variation from state to state, and within different organizations. To clarify these

terms and to improve your understanding of how they are used in this manual, a

brief explanation is provided below:

Executive Director

This is the person responsible for the day-to-day operations of

Vantage Pointe Village or residential care community. Some

state regulations specify other terms for this individual, such as

manager, and many organizations will refer to this person as the

"Executive Director."

Community

The care setting is referred to as a Vantage Pointe Village or residential care community. Although the term "facility" is often used in state regulations and by some in the industry, we feel it is important to distinguish a Vantage Pointe Village or residential care residence as a home, rather than strictly a clinical facility.

When the word "community" is used in this manual it is referring

to the care setting, not the community at large. Clarification will

be provided if necessary. In some cases, such as when quoting

from regulations, the term facility will be used.

Personal

Assistant

This is the person providing care. Although there are

exceptions, typically this person is not a licensed medical

professional.


Designated Many of the policies in this manual will refer to the "designated

Representative representative." It is recommended that you replace this title

with the specific title of the individual(s) within your community

that are responsible for the policy or procedure being described.

Licensee

This is the person or organization that has obtained a license to

operate the Vantage Pointe Village or residential care

community from the appropriate state agency. In some cases

the Executive Director and licensee is the same person.

Nurses

Some policies and procedures in this manual refer to a nurse, if

your community does not utilize nurses, modify the policies and

procedures accordingly.

Physician

Many policies in this manual recommend obtaining a "physician

order" or prescription. In many states and situations the order or

prescription can also be written by a Nurse Practitioner (NP) or

Physician's Assistant (PA).

Resident

The resident is the individual receiving care. In other healthcare

settings the term "patient" or "client" are more common, but to

foster a homelike atmosphere the term resident is used in the

Vantage Pointe Village and residential care industries.

Responsible

Party

Most residents living in Vantage Pointe Village or residential

care communities will have a responsible party. This may be a

family member with power of attorney, conservator, or another

individual or agency that is legally authorized to make decisions

on behalf of the resident.

GENERAL POLICIES


VANTAGE POINTE VILLAGE

POLICY AND PROCEDURE

MANUAL

General Policies

GENERAL POLICIES


POLICY: Personal Property/Theft and Loss

This Theft and Loss Policy and Procedure program will be reviewed twice a year

by all staff.

Personal Property

1. General

a. Residents will be encouraged to keep no more than $50.00 cash at

any time.

b. Residents will be requested to keep fine jewelry and other items of

value in a safe deposit box at their banking institution.

c. No items of value will be entrusted to the community for safe

keeping and no cash or other moneys will be entrusted to the

community.

d. The community does not have a safe on the premises to allow for

safe keeping of residents’ valuables. Residents are encouraged to

use their own private banking institution to provide this service.

The community provides all rooms with either a lockable door to

which the resident has a key, and/or a lockable cabinet to which the

resident has a key.

2. Inventory

a. The community maintains a current inventory of all personal

property identified by residents, unless the resident is able to

secure his/her room or refuses the inventory and the refusal is

documented.

b. When the inventory is complete, copies will be distributed to and

kept by the community, the resident, and the resident’s responsible

party.

c. The resident and responsible party are asked to notify the

community of any additions to, or removal of, personal property

inventory. The community will document appropriately.

d. In the event of a resident’s discharge or a resident’s death, the

inventory list will be verified and the personal items will be packed.

When the items are returned to the resident’s responsible party the

list will be re-verified and signed in receipt of belongings.

GENERAL POLICIES


3. Identification

a. Upon admission, all residents will be requested to appropriately

label all clothing and personal items.

b. All clothing will be labeled in an inconspicuous area (such as the

clothing tag) with permanent laundry markers to clearly identify

which resident they belong to.

c. All personal belongings that can be marked with permanent pen will

be marked in discreet locations.

d. In cases where the item or items cannot be safely labeled with a

non-erasable marker an electric pencil will be used to engrave the

resident’s name in a discreet place on the items, if the resident

agrees.

Theft and Loss

1. The community documents and appropriately investigates all alleged and

actual theft and loss of personal property.

2. Residents are encouraged to notify staff immediately if they notice a

personal item is missing.

a. Staff will conduct a thorough search for the missing item(s).

b. If the personal belongings cannot be found, an estimate of their

value will be assessed. The estimate will be the original purchase

price plus or minus any appreciation or depreciation that has

occurred.

c. If the theft exceeds $100.00 or more, a report shall be filed with the

appropriate local law enforcement agency.

d. All appropriate documentation of the incident will be given to the

responsible parties.

i. The community will maintain the records on file for a

minimum of three (3) years after the theft.

GENERAL POLICIES


Notification

1. The community notified all appropriate parties about the theft and loss

prevention program and provides them with copies of applicable laws.

2. The community posts the policy and procedures for safeguarding the

residents’ property in a common area accessible to all residents and

visitors.

3. Upon moving into the community, the resident and appropriate parties will

be notified verbally and given a copy of the theft and loss policy.

4. Copies of these procedures and applicable laws are available to anyone

upon request.

GENERAL POLICIES


POLICY: Abuse, Fraud, and Wrongdoing

The community takes all reasonable steps to prevent resident abuse and

neglect.

Residents, their responsible parties, personnel, health professionals and all

relevant stakeholders are encouraged to report in good faith any activity, policy

or practice, fraud, abuse and any other wrongdoing that he/she believes violates

professional standards of practice or is against the law, or poses a substantial

risk to the health, safety, welfare or rights of a resident.

Residents, their responsible parties, personnel, health professionals and all

relevant stakeholders may report such activities, policies or practices without fear

of restraint, interference, coercion, discrimination or reprisal. Reasonable efforts

are made to maintain the confidentiality of the resident, their family, personnel,

healthcare professional or relevant stakeholders.

The Executive Director will investigate any reports of abuse, fraud, or other

wrongdoing.

Procedure

1. All staff will receive training on elder abuse incidence, signs and

symptoms, and reporting requirements.

2. Residents, their responsible parties, personnel, health professionals and

all relevant stakeholders are encouraged to report any suspected

incidence of abuse, fraud, or other wrongdoing.

3. If a report of abuse, fraud, or other wrongdoing is received:

a. The Executive Director is notified immediately

b. Any urgent medical or safety issues are addressed immediately.

c. The Executive Director or other designated representative initiates

and investigation.

d. The resident's responsible party is notified.

GENERAL POLICIES


4. If the suspected abuse, fraud, or other wrongdoing is substantiated a

written report is made to the appropriate licensing/regulatory agency, the

responsible party, the Ombudsman, and Adult Protective Services.

5. All appropriate parties are notified of the outcome of the investigation.

6. Appropriate disciplinary actions will be made if community staff

participated in substantiated abuse, fraud, or other wrongdoing.

GENERAL POLICIES


POLICY: Personal Care Attendants

Residents who desire to use a personal care attendant for extended periods of

time may do so with the prior approval of the Executive Director.

Procedure

1. Resident needs may require a personal attendant, but must not require 24

hour skilled nursing care.

2. Personal Care Attendants from outside agencies may be used if approved

by the Executive Director. The agency shall ensure a criminal clearance

on all staff, health screening, appropriate insurance including liability and

worker’s compensation, proof of appropriate employer tax obligations,

including but not limited to withholding of state and federal taxes, payment

of disability and unemployment insurance. All appropriate labor laws are

to be followed and the Personal Care Attendant supervised by an agency

Executive Director familiar with this Vantage Pointe Village community

operations.

3. All Personal Care Attendants from outside agencies are to be fully trained

in all necessary care giving skills by the agency prior to coming in the

Vantage Pointe Village community to serve a resident.

4. Personal Care Attendants may not perform any act not allowed by

regulation or law.

5. The Personal Care Attendant, if employed by an agency, is expected to

notify his/her supervisor and community staff of any change in resident

status.

6. The Personal Care Attendants, if employed by an agency, are not to

provide care at any time to any other resident in the community.

7. It is the responsibility of the agency to ensure proper training of the

Personal Care Attendant employed by the agency in emergency

procedures such as fire evacuation, disaster preparedness, etc.

GENERAL POLICIES


POLICY: Home Health Agencies

Residents may receive services from a Home Health Agency. Services will be

coordinated by the community Executive Director or Director of Wellness.

Procedure

1. Verify appropriate physician orders for the use of a Home Health Agency.

2. The Executive Director provides clarification of the scope of practice in an

Vantage Pointe Village community (e.g. prohibited conditions, etc.), as

well as community policies regarding privacy, sign-in/sign-out, reporting

suspected abuse, etc.

3. The community Executive Director, resident, and other appropriate parties

will be involved in the development of the Home Health Agency plan of

care.

4. Home Health Agency staff are expected to check-in with the Executive

Director when arriving at the community and when leaving.

5. The Home Health nurse should notify the Executive Director of any

significant change in a resident's condition/services to provide continuity of

care and to allow for monitoring of prohibited or restricted conditions.

6. The Executive Director shall make the Home Health Agency aware of all

new orders, medication changes and response to interventions performed

by community staff.

7. The home health agency is expected to give notice to the resident of the

time of the visit.

8. A home health agency shall not provide training nor expect a non-licensed

care giver to perform any prohibited act/service in the community.

Examples of prohibited acts include, but are not limited to:

a. Non-licensed staff filling insulin syringes.

b. Dressing changes.

c. Wound irrigation.

GENERAL POLICIES


POLICY: Motorized Mobility Devices

Residents using motorized mobility devices, also known as scooters, are asked

to ensure the safety of all by observing the following rules.

Procedure

1. Written physician approval/authorization shall be received for each

resident using a motorized mobility device.

2. Carts are to be parked in the resident room or patio when not in use.

3. Carts are to be driven on the right side of hallways whenever possible.

4. Extreme caution is to be used when pulling out around blind turns,

corners, etc..

5. Carts are to be kept a safe distance behind all pedestrians, following the

manufacturer's guidelines for safe stopping distances.

6. Utmost courtesy is used to prevent rushing other residents on foot, in

wheelchairs or using other types of mobility aids.

7. Never drive carts when under the influence of alcohol or medications that

could pose a safety hazard, anywhere on the premises.

8. Personal Assistants will assist residents into any areas not safely

accessible by carts

9. In community rooms, carts should enter first and be the last to exit, unless

otherwise instructed for resident safety.

10. Always keep carts in good repair to ensure safety.

11. Appropriate insurance is to be carried by all cart drivers/owners with

minimum coverage in the amount designated by community.

12. Carts are to be driven on the lowest possible speed at all times when

indoors.

GENERAL POLICIES


POLICY: Resident Transportation

Resident transportation needs will be met.

Procedure

1. Before Transporting

a. Post notices of scheduled transportation in a clear, easy to read

format. Explain schedules to visually or other disabled residents.

b. Ensure special arrangements are made for residents with special

needs.

c. Resident’s families are asked to place transportation requests a

minimum of 36 hours prior to the appointed time.

2. For Resident Safety

a. Residents are to have the cognitive and physical ability to be

transported without assistance. This is to be verified by a physician

statement. Otherwise, residents are not allowed to be transported

without assistance.

b. Should a resident require accompaniment/assistance of any kind,

the Executive Director arranges such assistance prior to

transportation of the resident.

c. Community vehicle drivers are to be notified verbally and in writing

of all residents who are not safe to leave the building without an

escort.

3. All community drivers are to be appropriately licensed, in good health,

drug free and safe to operate a motor vehicle.

4. A safety check of the vehicle is to be performed by the driver before

operating the vehicle.

GENERAL POLICIES


POLICY: Resident Independent Departure

Assessment

Residents will be appraised for the ability to depart the community independently.

Procedure

1. Each resident will have a physician verification of the ability to leave

unescorted.

2. Should a physician not concur that the resident is able to leave without an

escort the resident will be encouraged to have staff accompaniment on

outings.

a. This is documented in the resident's record, and the responsible

party if notified.

3. Eviction will be considered for residents who are not safe to leave without

supervision, yet insist on leaving independently.

GENERAL POLICIES


POLICY: Sign-In/Sign-Out

Residents are asked to sign-in and out when arriving at and leaving the

community.

Dementia Note: Should the community serve residents with dementia a more

appropriate policy would be necessary.

Procedure

1. Residents are asked to sign out when leaving the community. The person

accompanying the resident is noted as well as the time.

2. Residents may not be required to disclose their destination. However, for

safety purposes the resident’s destination may be recorded if it is

voluntarily disclosed.

3. Residents leaving for extended periods should notify the front desk.

4. If residents are out during meal time, it is requested that staff be notified

that the resident will be out.

5. Upon returning to the community, resident or staff may sign them in.

GENERAL POLICIES


POLICY: Firearms

To ensure the safety of residents and staff firearms and ammunition are not

permitted within any part of the community.

Procedure

1. Prior to admission, residents will be informed of the prohibition of any

firearm or ammunition within any part of the community.

2. On admission the resident and or responsible party, as appropriate will be

asked if any firearm is being brought into the building.

3. Should a staff member suspect or identify a firearm or ammunition is

present in the community, their immediate supervisor is to be notified

immediately.

a. The Executive Director will be notified by the supervisor and

appropriate steps will be taken to remove the firearm.

b. If the resident refuses to allow the firearm to be removed, or at any

time staff or resident safety is in danger, the police or sheriff will be

notified immediately by calling 9-1-1.

GENERAL POLICIES


POLICY: Personal Rights

Staff will observe and respect the personal rights of all residents residing in the

community.

Procedure

Staff respects each resident’s personal rights, which include, but are not limited

to, the right:

1. To be accorded dignity in his/her personal relationships with staff,

residents, and other persons.

2. To be free from corporal or unusual punishment, humiliation, intimidation,

mental abuse, or other actions of a punitive nature, such as withholding of

monetary allowances or interfering with daily living functions such as

eating or sleeping patterns or elimination.

3. Leave or depart the community at any time and to not be locked into any

room, building, or on community premises by day or night.

4. To visit the community prior to residence along with his/her family and

responsible persons.

5. To have his/her family or responsible persons regularly informed by the

community of activities related to his care or services including ongoing

evaluations, as appropriate to the resident's needs.

6. To have communications to the community from his/her family and

responsible persons answered promptly and appropriately.

7. To be informed of the community's policy concerning family visits and

other communications with residents.

8. To have his/her visitors, including ombudspersons and advocacy

representatives permitted to visit privately during reasonable hours and

without prior notice, provided that the rights of other residents are not

infringed upon.

GENERAL POLICIES


9. To wear his/her own clothes; to keep and use his/her own personal

possessions, including his/her toilet articles; and to keep and be allowed to

spend his/her own money.

10. To have access to individual storage space for private use.

11. To have reasonable access to telephones, to both make and receive

confidential calls. The licensee may require reimbursement for long

distance calls.

12. To mail and receive unopened correspondence in a prompt manner.

13. To receive or reject medical care, or other services.

14. To receive assistance in exercising the right to vote.

15. To move from the community.

16. To have the freedom of attending religious services or activities of his/her

choice and to have visits from the spiritual advisor of his/her choice.

GENERAL POLICIES


POLICY: Dignity

Each resident has the personal right to be accorded dignity in his/her personal

relationships with staff, residents, and other persons.

Procedure

1. Staff are respectful and courteous in all interactions with residents.

2. Staff refer to residents by proper name (e.g. Mr. Smith or Mrs. Jones),

unless requested to use another name by the resident or responsible

party.

3. When addressing personal care needs (e.g. bathing), staff will speak with

residents in a private location.

4. Privacy is provided to avoid creating a sense of humiliation or

embarrassment for a resident.

GENERAL POLICIES


POLICY: Corporal Punishment and Restraints

Each resident has the personal right to be free from corporal or unusual

punishment, humiliation, intimidation, mental abuse, or other actions of a punitive

nature, such as withholding of monetary allowances or interfering with daily living

functions such as eating or sleeping patterns or elimination.

Procedure

1. Corporal or unusual punishment, humiliation, intimidation, mental abuse,

or other actions of a punitive nature are never used in caring for a

resident.

2. Physical or chemical restraints of any kind are never used in this

community.

GENERAL POLICIES


POLICY: Complaints

Each resident has the personal right to be informed by the Executive Director (or

a Director of Wellness) of provisions of law regarding complaints and of

procedures to confidentially register complaints, including, but not limited to, the

address and telephone number of the complaint receiving unit of the licensing

agency.

Procedure

1. At the time of admission the Executive Director (or a Director of Wellness)

informs the resident and his/her responsible party of the internal

community complaint policy and procedure.


informs the resident and his/her responsible party of the desire by the

community and all community to accommodate resident requests, needs,

complaints, and concerns.


provides the resident and his/her responsible party a method of contacting

the Ombudsman.


informs the resident and his/her responsible party of provision for

registering complaints with the state licensing agency. This includes, at a

minimum, the address and telephone number of the complaint-receiving

unit of the licensing agency.

5. Personal Assistants bring all resident requests, concerns, and/or

complaints to the attention of his/her immediate supervisor or the

Executive Director.

6. The Executive Director (or Director of Wellness) investigates all

complaints and discusses his/her findings with the resident and his/her

responsible party.

7. The Executive Director (or a Director of Wellness) reports all substantiated

serious or repeated complaints to the local state licensing agency (as

required by state regulation).

STAFFING




MANUAL

Staffing

STAFFING


Staffing Introduction

This section includes sample staff position titles, job descriptions, duty schedules

and forms used for communication with and between employees.

The manual uses the title Resident Care Coordinator for a supervisory position

for the Personal Assistants. Other titles commonly used for this position include:

• Vantage Pointe Village Director

• Director of Resident Services

• Director of Vantage Pointe Village

• Supervisor of Personal Care

• Shift Supervisors

This manual refers to the direct care providers in the Vantage Pointe Village

community as Personal Assistant. Again, there are other common names also

used within this industry such as:

Care Givers

Care Aids

Resident Aids

Personal Care Assistants

Resident Attendants

Certified Nurses Aids (only with proper certification)

Choose what fits your community best and make necessary changes to this

manual.

In this employee section there exists some “universal staffing,” in that you will

see Personal Assistants performing some housekeeping duties. The idea of

cross training may be greatly extended in your community or you may prefer a

more narrowly defined job role than what is described within these pages. There

exists tremendous flexibility within the Vantage Pointe Village and residential

care industry to staff in a manner which reflects the best standard of care based

on your resident population, size of community, and other factors. When working

within an Vantage Pointe Village community, the staffing patterns should reflect

the needs of your senior population.

This section is not intended as an exhaustive human resources reference, but

rather focuses on resident care issues and the providers of the direct care

services. In your community you will likely have addendum support staff in other

STAFFING


departments for such services as housekeeping, food services, groundskeepers,

maintenance, financial operations, etc.

POLICY: Staff Training

Direct care staff will Residents will receive initial orientation and ongoing in-

service training based on state regulations and the needs of the residents being

served in the community.

Implementation

1. Training on the following topics is included during Personal Assistant

orientation training and ongoing in-services.

a. Professional and ethical conduct, confidentiality, and reporting

requirements.

b. Promoting resident dignity, independence, privacy, self-

determination, choice and resident rights.

c. Abuse, neglect, exploitation and reporting requirements.

d. Fire, safety and emergency procedures, including identification of

unsafe environmental factors.

e. Infection control and Standard Precautions.

f. Emergencies, evacuations, disasters, incident reporting,

g. Advanced directives and Do-Not-Resuscitate Orders.

h. Psychosocial care and social, recreational activities.

i. Diversity: cultural, age, gender, sexual orientation, spiritual beliefs,

socioeconomic status, language, ethnicity, racial issues, etc.

j. End of life care and ethical issues.

k. Special care needs, aging issues, age-related limitations.

STAFFING


l. Providing physical care, assisting with ADLs, encouraging

independence, lifting and transferring techniques, use of care

equipment (e.g. lifts).

m. Nutritional issues.

n. Documentation and recordkeeping.

o. Service plans, assessments, appraisals, resident summaries,

person-centered care, and end of shift reports.

p. Dementia care, managing behavioral challenges, wandering and

elopement (as applicable).

q. First Aid and CPR (as applicable).

r. Medication management (as applicable).

2. All training will be documented. Copies of documentation will be retained

in the employee record.

STAFFING


POLICY: Job Description: Executive Director

Department: Administrative

Reports to: Licensee

Description of Position:

The Executive Director is fully responsible for community operations and quality

of care. Financial stability of the community, staffing practices and day to day

operations are coordinated by the Executive Director to fall within the operational

guidelines of governmental agencies. The Executive Director structures the

environment which will produce the highest standards of non-medical care.

Responsibilities of the Executive Director:

1. Identify and develop community standards of care congruent with the

population seeking placement.

2. Project and develop a sound operating budget for the community.

3. Standardize operations of each department.

4. Maintain the community in compliance with regulatory agencies.

5. Develop sound policy and procedure for resident care.

a. Utilize a system of sound management which monitors quality standards on

an ongoing basis in all departments.

6. Develop and carry out a successful marketing program which maintains >

95% occupancy.

7. Approve all admissions.

8. Hire new staff and/or terminating of unsatisfactory staff.

9. Investigate theft/loss in the community.

10. Carry out the operating policy of the licensee.

STAFFING


POLICY: Job Description: Assistant Executive

Director

Department: Administrative

Reports Directly to: Executive Director


Provides direct supervision of department heads. Works with the community,

ensuring that the community is a positive choice for seniors in the area.

Coordinates all departments to promote outstanding community operations in

alignment with goals, budget guidelines and resident needs. Assumes

responsibilities of the Executive Director in his or her absence, following

community guidelines. Supervises operations to conform to regulatory

guidelines.

Responsibilities of the Assistant Executive Director:

1. Supervise all department heads to ensure community is operating

according to standards and in compliance with regulatory guidelines.

2. Implement department budget and approve or deny expenditures based

on the allocations set by the Executive Director.

3. Work within the community to place residents in need of a higher level of

care.

4. Market the community to prospective placements. Schedule and plan all

community outreach projects.

5. Coordinate move-ins with other department heads.

6. Assume full responsibility all regulatory guidelines forms and

documentation for residents and employees and ensure that

administrative operation is up to date and complete at all times. Secure all

admission paperwork prior to move-in.

7. Organize monthly resident and family council meetings as well as family

conferences.

STAFFING


8. Prepare all licensing requests for exceptions, waivers and exemptions for

Executive Directors review and signature.

9. Monthly review of vendor performance.

10. Initial screening for all new job applicants. Verify qualifications.

11. Criminal clearances and coordination of pre-employment documentation.

12. Coordinate employee performance reviews.

13. Investigate complaints, document and review with Executive Director.

14. Terminate unsatisfactory staff with approval from Executive Director.

15. Other duties as assigned.

STAFFING


POLICY: Job Description: Resident Care Coordinator

Department: Resident Care Services

Reports to: Executive Director


The Resident Care Coordinator works as a liaison between residents, resident

families, and staff. The Personal Care Coordinator’s duties also include problem

solving resident concerns and coordinating care with the Personal Assistants.

The Personal Care Coordinator may be an RN or LVN when necessary.

Staffing Pattern:

The community has one Personal Care Coordinator position, on days only. This

is the chief supervisory position for the Personal Assistants who provide primary

care to their resident assignment.

Responsibilities of the Personal Care Coordinator:

1. Personal Assistant scheduling and resident assignments, working within

the department allowances.

2. Coordinate admissions with assistant Executive Director including

supervising move-ins to be sure accommodations are as desired and care

is immediately implemented.

3. Family/resident admission interviews.

4. Immediately bring prohibited conditions or at-risk residents in need of a

higher level of care to the attention of the assistant Executive Director.

5. Coordinate care planning with home health agencies on site, working

within community policy.

6. Arrange for transportation as desired by the resident.

7. Arrange for resident special needs involving other departments, verifying

follow through.

STAFFING


8. Function as a liaison with families ensuring special

needs/requests/complaints are addressed. Inform assistant Executive

Director, in writing and verbally, of all family or resident complaints.

9. Monitor staff performance, providing or arranging assistance as needed.

10. Read all communication notes regarding the community between the

Personal Assistant shifts.

11. Coordinate staff training and in-service schedules with the Assistant

Executive Director

12. Supervise the medication room and orders, working with and supervising

Medication Aides and Personal Assistants.


STAFFING


POLICY: Job Description: Medication Aide


Reports to: Personal Care Coordinator


Coordinates resident care related to medications by working with all

departments, the medical community, families and administrative staff to provide

for resident needs with continuity and an adherence to the scope of practice and

licensure for the community. Provides complete supervision of the medication

room, pass techniques, documentation and supervision and provision of care

related to medication in the community.

Staffing Pattern:

The community has one Medication Aide on each shift.

Responsibilities of the Medication Aide:

1. Resident charts. Keeping documentation current (Community forms,

licensing documentation, physician orders, incident reports., etc.)

2. Communicate resident status changes.

3. Ensure all medication documentation is current and correct, including

medication administration forms, physician orders, change of dosages,

written orders to confirm telephone orders, etc.

4. Ensure medication room is completely stocked with all required

continuous, PRN, Over-the-Counter (OTC), and other medications as

ordered by the physician.

5. Coordinate medication orders and deliveries with pharmacies

6. Communicate with physicians and other healthcare providers as needed.

7. Monitor Psychotropic med use is congruent with physician orders and

ensuring resident behaviors actually warrant the use of medication.

STAFFING


8. Control medication room access and key assignment.

9. Pour, pass, and assist with administration of medications in accordance

with state regulations.

10. Coordinate physician and other medical appointments.

11. Read all communication notes regarding the community between the

Personal Assistant shifts.


STAFFING


POLICY: Job Description: Personal Assistant


Reports Directly to: Personal Care Coordinator


Provides direct personal care and supervision to the residents at the community.

Promotes resident well being and satisfaction through support with activities of

daily living. Communicates with other departments to ensure resident needs are

met.

Staffing Pattern:

The Resident Care Services department at this Vantage Pointe Village

community staffs through a primary care structure. Each Personal Assistant will

be charged with all of the personal care duties of their resident assignment.

Whenever possible each Personal Assistant will be assigned to the same

resident group each day to promote continuity of care.

Responsibilities of the Personal Assistant:

1. Assist with activities of daily living, including passing medication as

assigned, following community protocol, licensing regulation and

guidelines for both resident and employee safety.

2. Follow safety guidelines in the community, including proper lifting

technique and universal precautions when providing care to the residents.

3. Follow the schedule of duties for the Personal Assistant, as well as the

individual plan of care for each resident.

4. Function as a team, assisting coworkers as the need arises.

5. Monitor resident activity, food intake, functional status, psychosocial

status, taking action as required to promote resident wellbeing.

6. Report status change immediately to the supervisor.

STAFFING


7. Act immediately on any resident crisis, following protocol and basic first

aid training.

8. Document resident status change, including but not limited to, physical

change, reaction to medication, psychosocial status change.

9. In the event all assigned duties cannot be completed, ask for assistance

and report to the personal care coordinator.

10. Any other assignments made by your direct supervisor or Executive

Director.

11. Promote open communication between health care professionals, families,

residents and staff.

12. Adhere to guidelines in the employee handbook including dress code,

conduct, scheduling, etc.


STAFFING


POLICY: Volunteers

Students and/or volunteers will be utilized as appropriate. Procedures will

ensure the safe, competent and mutually beneficial performance of volunteers.

Implementation

1. Signed Agreement

a. All volunteers will sign a written volunteer agreement.

2. Job Functions

a. Volunteers work under the direct supervision of the Director of

Activities.

b. Job functions will be specified by the Director of Activities for each

volunteer.

c. Job functions may include: assisting with activity programs,

assisting during activity outings, organizing activity supplies,

arranging for outings and special events.

d. All job functions will adhere to state-specific regulations.

3. Scope of Responsibility

a. Volunteers will not be assigned responsibility to supervise

community staff, Personal Assistants, nurses, etc.

b. Volunteers are responsible for ensuring the safety, well-being and

personal rights of residents involved in their activities.

4. Criteria for Use/Supervision

a. Use of volunteers will adhere to state-specific regulations.

b. Volunteers are under the direct supervision of the Director of

Activities.

STAFFING


5. Orientation and Training

a. Volunteers will receive necessary orientation and training from the

Director of Activities.

b. Orientation and training will address:

i. Introduction to program and philosophy.

ii. Volunteer responsibility.

iii. Attendance.

iv. Reporting.

v. Safety.

vi. Delayed egress and/or alarm systems (if applicable).

vii. Confidentiality.

viii. Abuse reporting.

ix. Overview of resident-specific care or health issues.

6. Dismissal

a. Volunteering is at the mutual consent of the community and the

volunteer. Either party may terminate the relationship at any time,

with or without cause and with or without advance notice.

7. Confidentiality

a. Volunteers will respect and ensure the confidentiality of all resident,

staff and community information.

ADMISSIONS AND MOVE-IN




MANUAL

Admissions and

Move-In



POLICY: Resident Pre-Admission Appraisal

The Executive Director will gather data on each potential resident to determine

the need and type of services to be provided.

Procedure

1. The Executive Director meets with the resident and responsible party prior

to admission.

2. The Resident Appraisal is completed by the Executive Director.

3. The Executive Director begins the pre-placement meeting with proper

introductions and explanations to promote a milieu of trust, comfort, and

honesty. Open-ended questions are encouraged. Consent is obtained for

the appraisal.

4. The purpose of the appraisal is explained: to determine the level and type

of services/care needed by the resident and that will be available for the

resident at the time of move-in, as well as to meet state licensing

requirements. The resident and/or family is assured by the Executive

Director that honesty and detail regarding care needs is in the best interest

of the resident.

5. Communicate acceptance by use of proper body posture, nods of

understanding and allowing the resident ample opportunity to answer

questions.

6. The Executive Director reviews the Physician Report for any prohibited

conditions or communicable illness.

7. Absence of TB must be evidenced by a physician report or chest x-ray

within the last six months.

8. The resident and/or responsible party are questioned about skin

breakdown.

9. A medication review will include the following:

a. Review of all medications on hand or reported.



i. NOTE: A physician order is to be obtained prior to

admission day, verifying medications and dosing schedule.

b. Specifically ask about the use of OTC (Over-The-Counter)

medications and complimentary or alternative medicines. Note any

preferred OTC medications to ensure physician orders are secured

prior to admission.

i. NOTE: This is an opportunity for resident teaching regarding

the storage and use of OTCs, related to regulatory

guidelines.

c. Should a resident desire to retain his/her OTC medications, a

physician order is obtained indicating the resident may self-store

and self-administer medications.

d. When OTC medications are centrally stored, a physician order is

required for all routine medications prior to assisting with the

medication.

e. When the OTC is a PRN and centrally stored, the following must be

included in the physician order:

i. Name of drug

ii. Strength of drug

iii. Dosage

iv. Exact time frames between doses

v. Maximum dose in a 24 hour period

vi. Symptoms for which the medication is used

10. Information regarding alcohol consumption is obtained.

11. Prohibited health conditions and/or residents significantly at risk are

identified. See the policy on prohibited health conditions for more

information.



POLICY: Allowable Health Conditions

The community will admit and retain stable residents with health conditions that

can be safely cared for by community staff and are in compliance with state

licensing agency guidelines.

Procedure

1. A physician's report is reviewed prior to placement to verify diagnoses and

health conditions.

2. The Physician Visit form is used to monitor health status changes after the

resident is admitted.

3. The following are examples of health conditions/needs that may be

managed in the community.

a. Use of oxygen when blood gases are stable and the resident is

capable of self-administration.

b. Colostomy, when the resident is able to manage all aspects of the

condition.

c. Ileostomy, when the resident is able to manage all aspects of the

condition.

d. Incontinence (both bowel and bladder).

e. Stage I and II decubitus ulcers.

f. Post-surgical wounds when the wound is well approximated.

g. Diabetes, including insulin-dependent, providing the resident has

reasonable stability, and is able to self-test and self-inject.

h. Inhalation therapies.

i. Hospice, providing a Medicare certified hospice agency, contracted

by the resident/responsible party, is coordinating the care.



4. Mild to advanced dementia, providing the community is appropriately

licensed.

5. Before accepting or retaining a resident with any of the above allowable

health condition, an assessment/evaluation of the resident must be

completed to confirm:

a. Resident's ability for self-care.

b. Compliance with the care routine to maintain medical stability and

consent to additional services whether by the community staff or

outside contracting agencies.



POLICY: Day of Admission/Move-In

The resident’s needs are addressed during the move-in process.

Procedure

1. The Executive Director coordinates the following on move-in day to ensure

appropriate resident care.

a. All preadmission documentation is complete and in the resident’s

chart.

i. The chart is appropriately labeled and organized.

b. The service plan is completed.

c. All physician admission orders are received.

d. Medications

i. All new prescriptions are sent to the pharmacy for same day

delivery, or if using existing fills, medications are verified.

ii. The medication cart/storage area is labeled and organized.

iii. The MAR (Medication Assistance Record) is set up,

including resident photograph in place.

e. Personal Assistants are assigned to assist the resident to put

belongings away and settle into his/her room.

i. The assigned Personal Assistant checks with the newly

placed resident every 4-6 hours for the first 24 hours of

placement, unless otherwise requested by the resident.

5. The Executive Director meets with the resident at the time of move-in for a

brief safety survey of the room and to verify that the resident is stable.

6. The Executive Director orients Personal Assistants about the needs of the

newly admitted resident on each shift.



POLICY: Change in Condition

When a resident exhibits a change in condition, action will be taken to coordinate

appropriate care.

Procedure

1. When a resident displays a change in condition, Personal Assistants notify

the Executive Director.

2. If a change in status progresses to an emergency at any time, call 911.

3. Examples of change in condition may include, but not be limited to:

a. Refusal of meals

b. Decreased mobility/range of motion

c. Change in patterns of elimination

d. Weakness

e. Decreased coordination

f. Change in level of consciousness

g. Decreased communication/response

h. Decreased ability to communicate signs

i. Decline in cognitive function

j. Motor agitation or retardation

k. Hallucinations or other unusual behavior

l. Nausea



m. Vomiting

n. Elevated or subnormal temperature

o. Wheezing

p. Shortness of breath or exertion

q. Complaints of pain or discomfort

r. Edema or swelling

s. Change in usual range of vital signs

t. Reaction/side effect to medications

u. Weight loss

v. Depressive behaviors

w. Falls

4. If there is an actual change in condition the resident’s physician is notified.

Always have the resident’s complete chart, list of meds, current vital signs

(if available), and concise list of problems available when calling the

physician.

5. If this is part of an ongoing problem and home health or hospice are

following the resident, contact the home health or hospice nurse and

explain the situation at hand.

6. Document the date and time of contacts, and with whom you spoke.

Clearly document any new orders and repeat back to the physician.

7. Immediately enter the new orders on the resident’s service plan and/or

medication administration record if the order pertained to medications.

8. Notify the resident’s responsible person of the change in status and action

taken.

9. Keep the Executive Director abreast of the resident’s response to the new

orders.



10. Report the status change and new physician orders to each shift.

11. If the resident status change results in a prohibited health condition, a

conference will take place with the Executive Director to determine the

resident’s suitability for retention. The Executive Director will file for an

exception if required.

12. If the resident requires skilled monitoring due to the status change, the

Executive Director consults with the physician to obtain an order for home

health.

13. The Wellness Director documents, schedules and follows through with any

continuing physician appointments and medical care.

14. If the resident status change is more than a transient problem, a resident

care conference is arranged.



POLICY: Ongoing Resident Appraisals

Residents are assessed/evaluated on an ongoing basis.

Procedure

1. Daily Evaluations

a. All staff members are encouraged to informally monitor residents

on a regular basis throughout the course of normal daily activities,

and to report any changes in condition that are identified.

2. One-Month Resident Appraisal

a. Resident will be formally assessed thirty days after admission.

b. The Executive Director meets with the resident and/or responsible

party to verify the resident’s needs are met.

c. The Executive Director consults with other Personal Assistants and

staff to ensure the resident’s needs are met.

d. The service plan is updated as necessary.

3. Quarterly Resident Appraisal

a. Residents are formally assessed on a quarterly basis.

b. The service plan is updated as needed.

c. Rates are adjusted, congruent with care delivered, and in

accordance with the terms of the admission agreement.

d. The Wellness Director consults with other Personal Assistants and

staff to ensure the resident’s needs are met.

4. Stakeholders

a. The following key stakeholders are encouraged to participant in

resident appraisals and service plan updates:



i. The resident

ii. The Executive Director

iii. The resident's responsible party

iv. Selected members of the community's care staff

v. Appropriate healthcare professionals (e.g., home health

nurse, physical therapy, etc.)

vi. The resident's physician



POLICY: Activity Assessments

The activity preferences of each resident will be determined to aid in the

development of a resident-centered activity plan.

Procedure

1. The Executive Director or a designated representative interviews the

resident and his/her responsible party regarding the resident’s personal

activity history and preferences.

2. The following domains should be addressed during the interview:

a. Gross motor activities

b. Daily living skills

c. Self-care activities

d. Crafts

e. Interest in social programs, games, music

f. Interest in large and small group participation

g. Social events

h. Community activities

i. Sensory enhancement, tactile stimulation

j. Outdoor activities, field trips

k. Family events

3. Use the Resident Activity Assessment form to document the assessment.

4. Information from the assessment is used to develop a resident-centered

activity plan and schedule.



POLICY: Admission Agreements

Each resident (or responsible party) signs an admission agreement prior to

admission.

Procedure

1. The resident and his/her responsible party is provided a copy of the

admission agreement prior to admission.

2. Prior to admission, the Executive Director meets with the resident and

responsible party to discuss the agreement as well as all fees and the plan

of care.

3. The admission agreement must be signed prior to admission.

4. Resident is given a thirty day notice of any subsequent changes to the

agreement.



POLICY: Service Plans

A resident-centered service plan is created and maintained for every resident.

The purpose of the service plan is to provide a centralized coordination of the

services that will be provided to each resident, based on his or her individual

needs, abilities, and preferences.

Procedure

1. The Executive Director, or a designated representative, develops a service

plan for each resident prior to admission.

2. The service plan is developed with assistance and review from:

a. The resident.

b. Family/significant other or responsible party.

c. The Executive Director (or designee).

d. A registered or licensed nurse, if the resident is receiving nursing

services, medication assistance, or is unable to direct self-care.

e. The resident’s case manager (if applicable).

f. The team may also include (at resident’s or responsible party’s

request): community personnel, his/her physician, and other

persons as requested.

3. The service plan should address, but is not limited to, the following:

a. Activities of Daily Living (ADLs).

b. Medication management and/or assistance required.

c. Physical needs related to illness/chronic disease management.

d. Psychosocial needs including activities

e. Behavioral challenges/needs



f. Spiritual needs.

g. Fall history and/or risk.

h. Nutritional needs such as help with eating or special diet.

i. Skin integrity issues.

j. Any need identified by the family or resident.

k. Activities.

l. Transportation needs.

4. A copy of the service plan is available to all staff for review.

5. A current copy of the service plan, signed by the resident and/or

responsible party is retained in the resident’s record.

6. All direct care staff are encouraged to give input on service plan changes.

7. Formal review takes place:

a. Thirty days after admission.

b. Bi-annually.

c. Annually.

d. Upon significant change in resident status/condition.



POLICY: Resident Care Conference

The resident care conference is intended to encourage a multidisciplinary

approach to resident care planning that involves input from all relevant

stakeholders.

Procedure

1. Purpose of Resident Care Conferences:

a. To identify individual resident needs.

b. To collaborate with all stakeholders in the coordination of optimal

resident care, ensuring clear communication of the plan of care.

c. To evaluate effectiveness of previous interventions and current

resident status.

d. To develop resident-centered interventions and methods of care for

the individual resident.

e. To coordinate discharges/evictions for those residents at risk for

transfer trauma.

2. Indications for Resident Care Conference:

a. Upon admission of a new resident.

b. Upon readmission of a resident if there has been a change in status

or previous functional abilities.

c. Resident is at risk of move-out or discharge.

d. Change in resident status or condition.

e. Annual resident appraisal and service plan review.

3. Attendees at the resident care conference may include, but are not limited

to:



a. Executive Director

b. Wellness Director

c. Appropriate department heads.

d. The resident

e. The resident's responsible party

f. Home health nurse

g. Other health care providers as appropriate (e.g., hospice, physical

therapy, etc.)

4. Documentation/Information

a. Conferences are to be resident focused at all times. It is the

responsibility of the Wellness Director to have all of the following

information available at the conference:

i. Resident’s history.

ii. A copy of the entire resident charting for the last 60 days.

iii. List of current medications.

iv. Significant health history.

v. Incident reports.

vi. Current service plan.

vii. All other relevant history and information.

viii. Current MD orders.

5. Suggest Conference Agenda

a. The conference general agenda is as follows:

i. Identify the resident.



ii. State purpose of conference (at risk, status change, etc.)

iii. Brief history.

iv. Current medications & Physician orders.

v. State chief problems/concerns.

vi. Discussion/identification of needs.

vii. Review/critique of previous interventions and plan of care.

viii. Discussion, revision and formulation of current plan of

action.

ix. Interventions.

x. Identification of individuals to carry out each intervention.

xi. Schedule of follow up conference date (as necessary) to

evaluate status and interventions.



POLICY: Move-Out

Residents may move out of the community for a variety of reasons, such as

increased need for healthcare services, a change in condition, or family/personal

reasons. A move-out of the community (discharge) is conducted in a dignified

manner to limit transfer trauma and to ensure that resident needs are met.

Procedure

1. The Executive Director coordinates the timing of the move-out with the

responsible party and receiving community or new residence.

2. If ambulance transportation is necessary, it is arranged by the Wellness

Director or the nurse on duty.

3. The Wellness Director assigns a staff member to assist resident with

collecting and packing belongings, as needed.

4. The resident is dressed in appropriate street clothing if going by car.

Gown, pajamas, etc., may be worn if going by ambulance.

5. The Personal Assistant assigned to the resident ensures hearing aid,

dentures, etc., are in place and appropriately accounted for.

6. The resident’s medications are counted and packaged appropriately for

transportation. The person receiving the medications upon transfer signs

for their receipt, accepting and acknowledging responsibility for

safekeeping.

7. All treatments and medication given within the last 24 hours are indicated,

and passed on to the new community.

8. A resident move-out summary is completed in the resident's record.

9. The resident's record is archived.

RESIDENT CARE




MANUAL

Resident Care

RESIDENT CARE


POLICY: Basic Care Services

Personal care will be provided to all residents on an individual basis according to

findings from admission appraisals and subsequent re-appraisals.

All resident care is planned and delivered in a resident-centered manner, and

personal service plans should address any individual resident needs.

Procedure

1. At the beginning of each shift, staff should familiarize themselves with

resident status. Clear communication with staff from the previous shift,

using the shift report and verbal exchange, ensures quality care.

2. Each resident is monitored on a routine basis. Check on residents every

two hours, unless indicated otherwise on the resident’s service plan.

a. NOTE: Residents with confusion or a diagnosis of dementia should

be checked on an on-going basis.

3. Incontinent care is given as necessary to residents requiring assistance

every two hours. This includes nighttime hours, unless the physician

orders indicate otherwise.

4. Medications are to be given according to physician orders and when

possible according to the following general medication pass schedule.

a. Morning medication pass: 7:00 A.M.

b. Mid-day medication pass: 11:00 A.M.

c. Evening medication pass: 5:00 P.M.

d. Bedtime medication pass: 8:00 P.M.

e. A "two-hour window" ensures appropriate delivery of medications.

Medications may be passed one hour earlier or one hour later

unless indicated otherwise by the physician or authorized

prescriber.

RESIDENT CARE


5. PRN medications are administered according to physician orders, resident

requests, and state regulations.

6. Residents are assisted with morning care as needed, which may include

but is not limited to the following :

a. Clothing selection.

b. Dressing.

c. Oral care.

d. Assistive devices, such as eye glasses, hearing aids, etc.

e. Shaving.

f. Cosmetics.

g. Hair care.

7. Residents are to have a full shower/bath according to their needs and

preferences, and at least twice per week.

8. Residents needing a reminder or assistance with ambulation or escorts

are to receive assistance to the dining room as needed for all three meals

and snacks as necessary.

9. Each resident is to have his or her room tidied and bed made each day if

unable to do so independently. Complete cleaning of their quarters is

performed by housekeeping staff on a weekly basis.

10. Residents are encouraged to select and attend activities. It is the

responsibility of the Personal Assistant to remind the resident of upcoming

activities throughout the day.

11. Residents receive assistance with bedtime/evening care as needed, which

includes, but is not limited to the following:

a. Oral care.

b. Dentures in a labeled cup.

RESIDENT CARE


c. Assistance into night clothes.

d. Toileting.

e. Incontinence care.

f. Safety check of the room.

g. Remove physical obstacles to the bathroom, and leave a low light

on in the bathroom.

h. Room set to a temperature desired by/comfortable for the resident.

i. Monitor noise level.

12. Any unusual incident will be reported and documented. All pertinent

information on the resident will also be documented and passed on to the

following shift.

13. Resident status changes will be reported to the physician and resident's

responsible party, in accordance with the policy on Change in Condition.

RESIDENT CARE


POLICY: Use of Assistive Devices and Ambulatory

Aids

The community promotes resident safety by allowing and encouraging the use of

resident assistive devices and mobility aids.

Implementation

1. The physician report and any pre-admission documentation will be

reviewed prior to placement, identifying resident need for assistive devices

or mobility aids.

2. The resident and responsible party are interviewed regarding resident

need for assistive devices or mobility aids.

3. Upon admission, the resident’s assistive devices and mobility aids are

labeled with name and room number.

4. Upon admission, residents are instructed about use of devices/aids within

the community:

a. Use in dining room.

b. Storage of devices for safety.

5. When a resident receives a new order for a mobility aid, the physician is

contacted to request a physical therapy consult for resident teaching.

6. In the dining room or common areas where an activity may cause some

congestion, resident’s mobility aids are moved to a designated area, once

the resident is seated safely. Staff will return the device to the resident

upon request, when the resident is ready to ambulate.

7. Any resident using a motorized scooter must demonstrate safe operation

of the device to the Executive Director. The Resident Care Coordinator also

obtains a written order verifying the ability for safe operation from the resident’s

physician. The resident must be re-evaluated for safety should any impaired

operation take place.

8. Safe use of mobility aids and assistive devices is included in staff

orientation.

RESIDENT CARE


POLICY: Hygiene and Grooming

The resident’s hygiene and grooming needs are met while addressing the

resident’s personal preferences and daily routine.

Implementation

1. The Resident and responsible party are interviewed prior to move-in to

determine the resident’s preferences for the provision of hygiene and

grooming care.

2. The resident’s physician report and appraisal are reviewed to identify

resident needs and preferences.

3. Special care needs are addressed in the resident’s service plan.

4. Residents are showered daily if desired, and at a minimum twice a week.

Exceptions are allowed for residents with special conditions or needs,

such as skin disorders or certain disease processes.

5. Bed baths are given upon evidence of need. The Resident Care

Coordinator approves bed baths to be given on a regular basis.

6. Refusal of necessary hygiene and grooming is reported by Personal

Assistants to the Wellness Director and/or Executive Director. Continued

refusal of hygiene and grooming is noted in the narrative charting section

of the resident’s chart, and the Executive Director is notified for further

action.

7. Resident autonomy is encouraged. Residents are not encouraged to

accept services when there is evidence they are capable of providing

selfcare adequately.

8. Assistance is scheduled as indicated in the service plan.

RESIDENT CARE


POLICY: Dressing

The resident’s need for assistance with dressing is met in accordance with the

resident’s personal preferences.

Implementation

1. The resident’s physician report will be reviewed to determine if assistance

is required.

2. Resident and family/responsible party are interviewed prior to move-in to

determine the resident’s preferences for the provision of hygiene and

grooming care.

3. Residents requiring assistance with dressing are encouraged to perform

as much of the task as possible.

4. The resident is expected to select or participate in the selection of his/her

clothing.

5. Residents are dressed in “street clothes” when in common areas of the

community.

6. Residents are assisted with additional clothing changes throughout the

day as needed.

RESIDENT CARE


POLICY: Sleep and Rest

Sleep disturbances will be addressed to promote appropriate rest.

Procedure

1. Residents with insufficient or poor quality sleep are monitored and/or

interviewed for possible causative factors. The Executive Director and

Personal Assistants monitor for:

a. Bedtime and waking times

b. Bedtime rituals

c. Type of bedclothes

d. Frequency and duration of awake time

e. Activities usually performed in the early evening hours

f. Leisure activities

g. Medications taken

h. Perceived health status and satisfaction with life

i. Food or fluids consumed shortly before bedtime

j. Number of nightly trips to the bathroom

k. Frequency of need for pain medications or for help with toileting

l. Time spent out of bed

2. The Wellness Director initiates changes in care to improve sleep, such as:

a. Maintain the same daily schedule for waking, resting, and sleeping.

RESIDENT CARE


b. Get up at the usual time even if the sleep has been disturbed or the

bedtime change temporarily.

c. Establish a bedtime ritual and stick to it.

d. Exercise every day but avoid vigorous exercises at night.

e. Limit naps to one or two hours per day, at the same time each day.

f. Take a warm bath in late afternoon or early evening.

g. Avoid caffeine-containing beverages and products.

h. Practice relaxation methods such as deep breathing, music,

rocking, massage, or reading calm materials.

i. Eat a light snack of carbohydrates and fat before bed.

j. If the resident is awake for longer than 30 minutes, get the resident

out of bed and engage in a non-stimulating activity such as reading.

3. When other methods have failed, the Wellness Director consults with the

physician for possible use of temporary sleep aids or other medical

interventions or assessments.

RESIDENT CARE


POLICY: Incontinence

Residents suffering with incontinence will receive care and management aimed

towards restoring continence whenever possible and preventing incontinence

related complications.

Procedure

1. Should a resident have an episode of incontinence, the Executive Director

consults with the physician to investigate the following:

a. Problems with manual dexterity or mobility.

b. Problems or changes in the environment (access, distance to

toilets, etc.)

c. Problems with excessive fatigue.

d. Difficulty or painful voiding.

e. Problems with constipation/stool impaction.

f. Changes in diet, including increase in caffeine.

g. Changes in medications, such as addition of a diuretic.

h. Changes in behavior/affect.

i. Mental status.

2. The Wellness Director instructs Personal Assistants to track episodes of

incontinence. If the resident is alert, encourage the resident to track

episodes themselves.

3. The Wellness Director transmits the information on episodes of

incontinence and other pertinent information to the resident’s physician.

RESIDENT CARE


4. The Wellness Director establishes a toileting schedule for staff to follow

when appropriate.

5. The Wellness Director consults with the physician to develop interventions

to correct incontinence whenever possible.

6. Should interventions fail and the resident is diagnosed with chronic

intractable incontinence, the service plan will include a skin management

plan.

7. Unless contraindicated, residents receive incontinent care and brief

changes every two hours, or more often as needed, to keep the resident

clean and dry.

8. Personal Assistants are instructed to monitor for and report any signs of

skin breakdown.

RESIDENT CARE


POLICY: Nutrition and Weights

The community monitors weights and provides modified diets as ordered by the

physician.

Procedure

1. The Wellness Director assigns the task of measuring resident weights to

Personal Assistants (after appropriate training) on a monthly basis.

2. Weights are measured more often if ordered by the physician.

3. Weight measurements are recorded in the residents record on the weight

record form.

4. Weights are measured using the following guidelines:

a. Prior to breakfast, after first voiding, and with the same amount of

clothing each day.

5. A weight change of five pounds or 5% of body weight in a 30-day period,

whichever is greater, is reported to the physician.

6. Nutritional supplements will be offered to the resident as ordered by the

physician.

7. Modified diets will be provided as ordered by the physician.

RESIDENT CARE


POLICY: Podiatry and Nail Care

The community will arrange for or make available foot and nail care.

Procedure

1. Personal Assistants monitor the length and condition of the toe and finger

nails of residents receiving bathing, dressing, or grooming services.

2. Personal Assistants note changes in residents’ nail or foot integrity.

3. Personal Assistants do not trim nails, smooth corns, calluses, etc.

4. The Wellness Director schedules a podiatry appointment for foot and/or

nail care, other than cleaning or moisturizing.

5. The Wellness Director arranges for regular (monthly preferred) onsite

visits by a podiatrist, as needed and as available.

RESIDENT CARE


POLICY: Personal Assistant Daily Schedule

Personal Assistants are given assigned duties to ensure quality care.

This is only a basic policy and schedule. Always refer to the resident’s individual

plan of care for additional intervention.

11:00 pm - 7:30 am

1. Verify resident status changes with the previous shifts. Read

documentation.

2. Rounds every two hours.

3. Incontinent care every two hours as assigned, and as needed.

4. Housekeeping duties as assigned.

5. PRN medications as needed (med aides only).

6. Awaken first serving breakfast residents.

7. Assist with designated early morning baths.

8. Assist as needed with grooming: Resident morning grooming (assist only

as required)

a. Bathing (on designated days)

b. Incontinent care

c. Clothing selection

d. Dressing

e. Oral care

f. Assistive devices in place

g. Shave

h. Make-up

i. Hair care

j. Mini appraisal

9. First serving residents to dining room.

RESIDENT CARE


10. Set-up and pass 7:30 am medications (medication aides only).

11. Assist second serving residents with personal care.

12. Document resident status change or incidents per community protocol.

13. Report off to next shift.

7:00 am - 3:30 pm STAFF DUTIES

1. Verify resident status changes with the previous shifts. Read

documentation.

2. Check schedule for resident physician or other scheduled appointments.

3. Designated resident baths.

4. Assist with resident grooming which was not completed by the night shift.

a. Bathing ( on designated days )

b. Incontinent care

c. Clothing selection

d. Dressing

e. Oral care

f. Assistive devices in place

g. Shave

h. Make-up

i. Hair care

j. Mini appraisal

5. Second service residents to dining room by 7:30 am.

6. Rounds every 2 hours.

7. Incontinent care every 2 hours as assigned.

8. Make beds.

9. Tidy rooms/housekeeping duties as assigned.

RESIDENT CARE


10. Pass am snacks.

11. Residents to 10:00 am activities.


13. Prepare and assist first serving residents to dining room for lunch.

14. Prepare and pass 11:30 am medications (med aides only).

15. Prepare and assist second serving residents to dining room for lunch.

16. Residents to early afternoon activities.

17. Afternoon grooming/room check.

a. Clean clothing

b. Wash face and hands

c. Tidy room

18. Pass afternoon snacks.

19. Document status change/incidents per protocol.


21. Med staff only.

3:00 pm - 11:30 pm

1. Verify resident status changes with previous shifts. Check documentation.

2. Rounds every 2 hours.

3. Incontinent care every 2 hours.

4. Housekeeping duties as assigned.


6. Set-up and pass 4:30 pm medications (med aides only).

RESIDENT CARE


7. First serving residents to dining room at 4:30 pm. Second serving

residents to dining room at 5:30 pm.

8. Residents to pm activities.

9. Set-up and pass 8:30 pm medications (med aides only).

10. Assist residents as needed with evening care.

a. Oral care

b. Dentures in labeled cup

c. Assist into night clothes

d. Toileting

e. Incontinent care

f. Remove soiled clothing and put in hamper

g. Remove assistive devices (hearing aids, etc.)

h. Safety check

i. Pathway clear to bathroom

j. Room a comfortable temperature

k. Extra blankets, etc.

11. Check lighting.

12. Outside doors secured. (from outside only)

13. Document status change/incidents per protocol.


RESIDENT CARE


POLICY: Sexual Expression

The community respects the resident’s need for sexual expression and intimacy.

Procedure

1. Resident privacy is observed by scheduling for private time, knocking on

doors before entering, etc.

2. Verify the resident’s ability to give consent by consulting with the resident’s

physician for residents interested in pursuing sexual relationships.

3. When a resident displays inappropriate sexual activity / exposure, have

staff remind the resident of the need for privacy and then move the

resident to his or her room.

4. Discuss the resident’s sexual behavior with Personal Assistants.

Reinforce the idea that sexual behavior is normal and that acknowledging

a resident’s sexuality is appropriate.

5. Educate families about resident rights related to sexuality and the

normalcy of sexual expression.

6. When a resident interacts or touches staff inappropriately, the Executive

Director reinforces care techniques to avoid such problems. For example:

a. Identify yourself when ready to provide care.

b. Stand at the side, rather than in front of the residents reach when

providing personal care.

c. Give the resident something to hold when providing personal care.

MEDICATION

MANAGEMENT




MANUAL

Medication

Management

MEDICATION

MANAGEMENT


POLICY: Medication Storage

Medications will be stored in a manner that ensures maintenance of both the

integrity of the medication and the safety of all residents residing in the

community.

Procedure

1. All medications, including over-the-counter, are kept in locked storage at

all times.

2. All medications must be stored in accordance with label instructions

(refrigerate, room temperature, out of direct sunlight, etc.).

3. Medication requiring refrigeration are stored in a separate, locked

refrigerator that is used solely for medication storage.

4. If resident is allowed to keep his/her own medications, the Executive

Director ensures:

a. Locked storage is maintained in the resident’s room to prevent

access by other residents.

b. Physician orders are on file in the resident’s chart indicating the

resident is able to store and self-administer his/her medications.

c. Quarterly evaluation of the resident’s ability to safety store and self-

administer his/her medications.

MEDICATION

MANAGEMENT


POLICY: Medication Records

Records of medications are maintained.

Procedure

1. A record of all medication brought into the community is maintained for

three years.

2. A record of medications that are disposed of in the community is

maintained for at least 3 years.

3. Written physician orders for all medications are maintained in the

resident’s chart in the “Physician Orders” section.

4. Medication Administration Records (MARs) are maintained for all

medications poured and/or passed by community staff.

MEDICATION

MANAGEMENT


POLICY: Telephone Orders

Telephone orders for medications are not permitted. Prescribers will be asked to

fax orders directly to the community.

Procedure

1. If a physician or other authorized prescriber attempts to give a telephone

order, he/she is asked to fax the order to the community.

2. Community staff may write the order on the appropriate form and fax it to

the prescriber for a signature.

MEDICATION

MANAGEMENT


POLICY: Medication Labels

Community staff does not alter prescription labels.

Procedure

1. Community staff does not alter prescription labels. In order to maintain a

label that matches the current physician’s order, the designated staff

person:

a. Without obscuring the original label, flags the container with a

brightly colored sticker and writes on it “order changed,” with the

date, time, and his/her initials.

b. The Director of Wellness highlights the old order in the MAR and

writes: “order changed,” with the date, time, and his/her initials.

c. The Director of Wellness transcribes the new order in the next

available space in the resident’s MAR.

2. The Director of Wellness discusses the change with resident and/or

responsible party.

3. The Director of Wellness ensures the new medication instructions are

transmitted to the pharmacy so consecutive refills are appropriately

labeled.

MEDICATION

MANAGEMENT


POLICY: Resident Arrives with a Medication

When a resident arrives at the community with a new medication, steps will be

taken to ensure proper storage and handling of the medication. Physician’s

orders will be verified for all medications.

Procedure

1. Each physician is contacted to ensure that the physician is aware of all

medications currently taken by the resident.

2. Containers are inspected by a pharmacist to ensure the labeling is

accurate.

3. The Wellness Director discusses medications with the resident or the

responsible party.

4. If the physician and Wellness Director agree that the resident is capable of

self-storage and self-administration of medication, the resident’s

medications are stored in a locked compartment in his/her room.

5. The medications are placed in the medication room in an appropriately

labeled drawer, bin, etc., if central storage is required.

6. The medications are appropriately listed on the MAR, verifying accuracy

according to physician orders.

7. All medications not self-stored or self-administered by the resident are

logged on to the Centrally Stored Medication Record.

MEDICATION

MANAGEMENT


POLICY: Medication Refills

Medication refills will be obtained in a timely manner to ensure residents have all

physician ordered medication available.

Procedure

1. The Director of Wellness contacts the dispensing pharmacy to obtain a

refill at least seven (7) days prior to running out of a medication, unless

medication is on a cycle refill with the pharmacy. When the medication is

ordered it is entered onto the Refill Roster. When medications are

received they are entered on the Refill Roster.

2. If necessary, the prescribing physician is contacted for a new order.

3. Medications are never allowed to run out unless directed to by the

physician (obtain this direction in writing).

4. Containers are inspected to ensure all information on the label is correct.

5. Any changes in instructions and/or medication are noted; for example,

change in dosage, change to generic brand, etc.

6. Medications are logged on the Centrally Stored Medication Record when

received.

7. The Wellness Director discusses any changes in medications with the

resident, responsible party and appropriate staff.

MEDICATION

MANAGEMENT


POLICY: Medications are Permanently Discontinued

Permanently discontinued medication will not be retained in the community.

Procedure

1. The Wellness Director confirms with physician the order to permanently

discontinue the use of the medication, and obtains written documentation

of the discontinuance from the physician, prior to destroying.

2. The Wellness Director discusses the discontinuance with the resident

and/or responsible party.

3. To properly dispose of permanently discontinued medications the

Wellness Director and another adult witness who is not a resident:

a. Returns the medication to the dispensing pharmacy for disposal; or

b. Disposes of the medication in a medical waste receptacle that is picked

up at regular intervals by a licensed medical waste company.

4. Medications to be returned to the pharmacy are held in a bin labeled

“return to pharmacy” in the medication room until the time of pick-up by the

pharmacy.

5. The Wellness Director and witness will document destruction on the

Centrally Stored Medication Record.

MEDICATION

MANAGEMENT


POLICY: Hold Orders

Temporarily discontinued ("dc") and/or “HOLD” medications will be held from use

by the resident as instructed by the physician.

Procedure

1. The Wellness Director discusses the change with the resident and/or

responsible party.

2. The Wellness Director obtains a written order from the physician to HOLD

the medication.

3. Without obscuring the label, the medication container is flagged with a

brightly colored sticker where the Wellness Director writes: “HOLD,” the

date, the time, and his/her initials.

4. The medication is not given to the resident until the date and/or time

indicated in the physician’s hold order.

5. The medication is placed into a plastic bin labeled “On Hold Medications”

in the medication room.

MEDICATION

MANAGEMENT


POLICY: Expired Medications

Expired medication will be not be given to any resident or responsible party, nor

retained in the community.

Procedure

1. Expired medications are not used.

2. The Director of Wellness inspect containers regularly for expiration dates.

3. The Director of Wellness communicates with physician and pharmacy

promptly to obtain a refill.

4. To properly dispose of expired medications the Director of Wellness and

another adult witness who is not a resident:


b. Disposes of the medication in a medical waste receptacle, which is

picked up at regular intervals by a licensed medical waste company.

5. The Director of Wellness and witness will document destruction on the


MEDICATION

MANAGEMENT


POLICY: Medications Left Behind by a Resident

When a resident moves out of the community, all medications, including over the-

counters, should go with resident when possible.

Procedure

1. If the resident dies, prescription medications are to be destroyed.

2. To properly dispose of medications left behind by a resident, the Director

of Wellness and another adult witness who is not a resident:


b. Disposes of the medication in a medical waste receptacle, which is

picked up at regular intervals by a licensed medical waste company.

3. The Director of Wellness and witness will document destruction on the


4. Document on Centrally Stored Medication Record when medication is

transferred with the resident. Obtain signature of person accepting the

medications (i.e., responsible party) will be obtained, indicating agreement

with the quantity of each medication transferred out of the community.

5. Medication records are retained for at least three years.

MEDICATION

MANAGEMENT


POLICY: Medication Refusal and/or Missed Doses

No resident will be forced to take any medication. Steps will be taken to avoid

missed or refused doses of medications and related adverse reactions.

Procedure

1. Missed/refused medications are documented in the resident's medication

record and the prescribing physician notified immediately or according to

physician parameters. Physician parameters must be retained in writing

and kept on file.

2. Physician instructions regarding missed dose are followed.

3. The Director of Wellness appraises the resident and contacts the

physician and responsible party if the resident is continually refusing a

medication(s). If unable to resolve continued refusal, the resident’s

relocation from the community may be necessary.

MEDICATION

MANAGEMENT


POLICY: Crushing Medications

Medications will be crushed in accordance with physician’s orders and state

regulations, without infringing on the resident’s personal right to refuse

medications.

Procedure

1. The Director of Wellness obtains a physician’s order prior to crushing a

resident’s medications.

2. The pharmacist is consulted to verify appropriate foods the medication

may be mixed with. This phone conversation is documented in the

resident’s chart.

3. The physician order and documentation of the telephone consult is

maintained in the resident’s record.

4. When crushing medications:

a. A pill-crushing device is used.

b. The completely crushed medication is mixed with an appropriate

soft food such as applesauce or pudding, not a liquid.

5. The resident is clearly informed that he/she is receiving medications.

MEDICATION

MANAGEMENT


POLICY: Transferring Medications for Home Visits

and Outings

Staff will assist resident to obtain/maintain necessary medications for use while

not in the community.

Procedure

1. When a resident leaves the community for a short period of time during

which only one dose of medication is needed, the Director of Wellness

gives the medications to a responsible party in an envelope (or similar

container) labeled with the resident's name, name of medication(s), and

instructions for administering the dose.

2. If the resident is to be gone for more than one dosage period, the Director

of Wellness may:

a. Give the full prescription container to the resident, or responsible

party, or

b. Have the pharmacy fill a separate prescription or separate the

existing prescription into two bottles, or

c. Have the resident's family obtain a separate supply of the

medication for use when the resident visits the family. If family

maintains a separate supply, the Director of Wellness supplies

them with current physician orders prior to every outing or home

visit.

4. The Director of Wellness reviews the resident’s physician orders, appraisal

and service plan to verify the ability of the resident to store and self-

administer medications while away from the community. If it is not safe to

give the medications to the resident, the medications are entrusted to the

person who is escorting the resident off the community premises.

5. The person entrusted with the medications agrees in writing as to the

amount of medication received on behalf of the resident and the

appropriate dosing amount and schedule.

MEDICATION

MANAGEMENT


POLICY: Sample Medications

Sample medications may be used when provided by the prescribing physician.

All safety controls imposed on other medications will apply to sample

medications as well.

Procedure

1. The Director of Wellness ensures that all sample medications received

into the community are provided by the prescribing physician.

2. Sample medications will be labeled with all the information required on any

prescription label except pharmacy name and prescription number.

3. Sample medications are centrally stored, documented and handled in the

same manner as other prescription medications.

MEDICATION

MANAGEMENT


POLICY: Use of Emergency Medications

Residents who have a medical condition requiring the immediate availability of

emergency medication (i.e. nitroglycerine, inhaler, etc.) for life-saving purposes

may maintain the medication in his/her possession if the safety the resident and

other residents can be maintained and state regulatory requirements are

followed.

Procedure

1. A physician order is received stating that the resident is capable of

determining the need for a dosage of the medication and has determined

that possession of the medication by the resident is safe.

2. This determination by the physician is maintained in the individual's file

and available for inspection by the state licensing agency.

3. The physician's determination clearly indicates the dosage and quantity of

medication that should be maintained by the resident.

4. Neither the community Director of Wellness nor state licensing agency

staff has determined that the medications must be centrally stored in the

community due to risks to others or other specified reasons.

5. If the physician has determined it is necessary for a resident to have

medication immediately available in an emergency but has also

determined that possession of the medication by the resident is

dangerous, then that resident may be inappropriately placed and may

require a higher level of care.

MEDICATION

MANAGEMENT


POLICY: Injections

Injectable medications will be administered by authorized licensed nurses or

physicians, according to physician’s orders and state regulatory requirements.

Procedure

1. Injections are administered only by the resident themselves or by a

licensed medical professional. Licensed medical professional includes

Doctors of Medicine (MD), Registered Designated staff persons (RN), and

Licensed Practical/Vocational Nurses (LPN/LVN).

2. Licensed medical professionals administer only medications/insulin that

they have drawn up, or have been pre-drawn by the pharmacy or the drug

manufacturer.

3. If the resident administers his/her own injections, physician verification of

the residents’ ability to do so is maintained in the resident’s record.

4. The Director of Wellness ensures sufficient amounts of medications, test

equipment, syringes, needles, and other supplies are maintained in the

community and stored properly.

5. Syringes and needles are disposed of in a "container for sharps," and the

container shall is kept inaccessible to residents. The container shall be

removed from the community by an appropriate medical waste company.

6. Insulin and other injectable medications are kept in the original containers

until the prescribed single dose is measured into a syringe for immediate

injection.

7. Insulin or other injectable medications may be packaged in pre-measured

doses in individual syringes prepared by a pharmacist or the

manufacturer.

8. Syringes may be pre-filled under the following circumstances:

a. Pre-filled syringes prepared by a registered nurse, may be self-

injected by residents who are able and approved to self-inject.

MEDICATION

MANAGEMENT


b. The registered nurse (RN) must not set up insulin syringes for more

than seven days in advance. The pre-drawn insulin is only for the

resident to self-administer. An LVN may not pre-draw insulin.

9. Injectable medications that require refrigeration must be kept inaccessible

to residents.

MEDICATION

MANAGEMENT


POLICY: Over-the-Counter (OTC) Medications

A physician order is required for all OTC medications.

Procedure

1. OTC preparations are centrally stored, documented and handled in the

same manner as prescription medications.

2. The Director of Wellness contacts the physician for prescriptions for OTC

preparations prior to their use.

MEDICATION

MANAGEMENT


POLICY: Psychotropic Medications

Psychotropic medications are given in a safe manner according to physician

orders. The community minimizes the use of psychotropic medications when

possible.

Procedure

1. Behavioral and environmental interventions are attempted to avoid over or

unnecessary use of psychotropic medications.

2. Personal Assistants are educated on appropriate interventions for anxiety,

agitation, dementia-related behavioral challenges, and potential adverse

effects of psychotropic medications.

3. The Director of Wellness encourages Personal Assistants to report

adverse effects such as extrapyramidal symptoms and tardive dyskinesia.

MEDICATION

MANAGEMENT


POLICY: Warfarin and Other Anticoagulants

Residents taking warfarin or other anticoagulants will receive assistance with

necessary monitoring and/or lab tests.

Procedure

1. Residents receiving Coumadin are instructed on signs and symptoms of

complications, and to report these immediately to their physician and to

the Executive Director.

2. Staff are trained on monitoring residents receiving warfarin (Coumadin) or

other anticoagulants.

3. The Executive Director makes arrangements for transportation to lab

appointments as required.

4. Lab results are reported directly to the prescribing physician.

5. The Medication Administration Record is updated immediately upon

receiving the Coumadin dosing change from the prescribing physician.

MEDICATION

MANAGEMENT


POLICY: Narcotics, Controlled Substances, and

Preventing Drug Diversion

All medications are stored in a secure manner, as outlined in other policies.

Special storage and security procedures will be followed to protect controlled

substances (narcotics, etc.) and to help prevent drug diversion.

Procedure

1. All medications, including over-the-counter medications, are kept in locked

storage at all times.

a. Only authorized staff members are given keys to the medication

storage area.

b. Staff members do not take keys home or otherwise off community

premises.

2. A Narcotic Count Sheet will be maintained for all narcotic medications.

a. When a narcotic is received in the community, it is counted by two

staff members and added to the narcotic sheet with the current

medication count reflected in the amount on hand.

b. Each time a resident receives assistance with self-administration of

a narcotic, this is documented and the amount of medication on

hand is updated on the Narcotic Count Sheet.

c. At the end of each shift, the staff member responsible for

medication completing his/her shift, and the staff member

responsible for medications who is starting his/her shift, count all

narcotic medications and confirm that the amount on hand matches

was it listed on the Narcotic Count Sheet for each medication. Both

staff members will sign a Narcotic Reconciliation Sheet confirm the

accurate count of narcotics on hand.

d. Any discrepancies are immediately reported to the Executive

Director.

MEDICATION

MANAGEMENT


3. When medications are to be destroyed, the destruction must be witnessed

by the staff member responsible for medications and a pharmacist. The

destruction is documented, including the amount of medication destroyed

and a signature from both witnesses.

4. Staff members will be trained to identify drug diversion and encouraged to

report suspected drug diversion to the Executive Director for proper

investigation.

a. Any drug diversion will be reported to the state licensing agency,

law enforcement, and any other agencies as required.

EMERGENCIES AND MEDICAL NEEDS




MANUAL

Emergencies and

Medical Needs



POLICY: Physician and Other Medical Appointments

The resident will receive assistance in obtaining necessary medical care.

Procedure

1. Residents and responsible parties are informed to notify the Wellness

Director of pending physician or other medical appointments.

2. The scheduled physician visits are entered on the physician appointment

calendar.

3. The following accompanies the resident on all physician visits:

a. Physician Visit form.

b. Photocopy of current MAR (originals are never sent).

c. Any other requested documentation (daily glucose reading, etc.).

d. The Physician Visit form is returned to the community and all orders

transcribed by the licensed Executive Director or supervisor on

duty.

4. Family/responsible party may transport the resident to appointments. The

Wellness Director instructs Personal Assistants to have the resident

appropriately dressed and ready for transport.

5. Should the resident not have transportation, the Wellness Director

arranges for necessary transportation.

6. If a resident is unsafe to be left without an escort, the Wellness Director

arranges for a staff member to accompany the resident.

7. Should the Wellness Director determine a resident is not stable, safe, or

comfortable enough for van/car transportation, arrangements are made for

ambulance transport.

8. It will be disclosed to the resident/responsible party upon admission, that

off-hour, unscheduled, or ambulance transportation is the financial

responsibility of the resident.



POLICY: Labs and Outside Medical Services

The resident will receive assistance with arrangements for outside medical

services.

Procedure

1. Residents and responsible parties are informed to notify the Wellness

Director of any pending outside medical services.

2. The scheduled service is calendared.

3. Should the resident not have transportation, the Wellness Director


4. If the resident is unable to be left without an escort, the Wellness Director


5. It is disclosed to the resident and responsible party upon admission, that

off hour unscheduled or ambulance transportation is the financial

responsibility of the resident.

6. The Wellness Director instructs all labs reporting or transmitting values to

directly transmit to the physician. Unlicensed Personal Assistants may not

take verbal lab values.



POLICY: Licensure of Nursing Personnel

Nursing personnel must present verification of such license prior to or upon

employment.

Procedure

1. At the time of employment, nursing personnel who require a license or

registration present verification of such license to the Executive Director.

2. A copy of the current license and registration number is filed in the

employee’s personnel record.

3. A copy of the annual renewal (as applicable) is presented to the Executive

Director.

4. If the validity or standing of a license is in question, the Executive Director

will contact the appropriate board for verification.

5. Until the license is verified, the nurse will not perform any duties requiring

licensure.



POLICY: Medical Emergencies

The resident will receive emergency medical care when needed to prevent

further injury or illness.

Procedure

1. Personal Assistants immediately summon the community Wellness

Director should a resident exhibit signs and symptoms of a medical

emergency.

2. The Wellness Director makes a determination as to the severity of the

situation.

3. The community summons emergency medical services by calling 911),

when the resident exhibits signs and systems of distress and/or

emergency condition. Examples include, but are not limited to:

a. New onset of chest pain;

b. Recurrent chest pain, unrelieved in 15 minutes by previously

ordered nitroglycerin given as ordered;

c. Unconsciousness;

d. Fall with deformity, severe pain or head injury;

e. Uncontrolled bleeding;

f. First time seizure;

g. Recurring seizure which last for more than 1 minute;

h. Sudden onset severe pain;

i. Shortness of breath;



j. Sudden lack of muscle control, ability to communicate, drooping

facial expression or other signs of stroke;

k. Low blood sugar (according to physician order parameters, usually

<60);

l. Excessively high blood sugar, according to physician order

parameters;

m. Poisoning;

n. Fever which is not lowering despite interventions and fever

reducing agents;

o. Choking;

p. Psychiatric crisis.

4. A non-emergency transport is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding, etc.

5. The Wellness Director contacts the family/responsible party, as quickly as

possible, once the resident is safely under the care of the paramedics.

Unless instructed otherwise by the family/responsible party, this includes

anytime, 24-hours a day.

6. The Wellness Director or Personal Assistants are not required to obtain

permission from the family/responsible party before summoning

emergency medical services.

7. A staff member remains with the resident until paramedics transport out of

the community.

8. A copy of the current MAR is given to the paramedics, along with the

Emergency Identification Form.

9. The actual medications are retained in the community.



10. The staff person observing the transport out of the community will note

what belongings are going with the resident, such as jewelry, dentures,

prosthetic devices, etc.

11. A narrative chart entry is made in the resident’s chart regarding the

circumstances which led up to the call (Data), what care was provided by

the staff, including any first aid (Action), as well as the resident’s response

to the action (Response).

12. An Incident Report is completed.



POLICY: Psychiatric Emergencies

Appropriate care will be arranged for should a resident be in psychiatric crisis.

Procedure

1. Personal Assistants immediately report to the Wellness Director any

significant change in resident affect, personality, or behavior.

2. Any verbalization of suicidal ideation are taken seriously by Personal

Assistants and reported to the Wellness Director.

1. NOTE: Should an Wellness Director not be on duty, suicidal ideations

would be reported to the immediate supervisor or medical professional.

2. Should a resident show evidence of violence (e.g. throwing objects,

attempting to strike another resident, etc.) other residents are immediately

removed from the area and assistance is summoned. Objects that could

be used as a weapon are removed from the area.

3. Physical force is not used to subdue a resident.

4. If the severe behavior continues, call 911. Monitor the resident until

assistance arrives.

5. An Incident Report is completed for all psychiatric crises and given to the

Wellness Director.

6. All psychiatric crises are reported to the resident’s responsible party.



POLICY: Falls

Should a resident experience a fall, staff will provide or arrange for necessary

emergency care, and will follow up with necessary service plan updates.

Procedure

1. Should the resident have trauma resulting in deformity, exhibit any change

in level of consciousness, received obvious head or significant trauma the

Wellness Director or Personal Assistants summon emergency medical

services (call 911).

2. When a resident falls Personal Assistants are instructed to summon

immediate assistance from the Wellness Director or Nurse Assistant.

3. Personal Assistants do not move the resident, except to protect against

further injury, as in the case of a dangerous environment.

4. The physician is contacted for further instructions if the head was not

involved in the fall and the resident is able to move all extremities.

a. The Wellness Director instructs Personal Assistants to provide

appropriate care and frequent resident checks. Any change in

status is reported to the Executive Director.

5. An incident report is completed.

6. The Wellness Director informs the physician of subsequent falls and

instability. Medical intervention, physical therapy, and/or gait analysis is

arranged when residents remain a significant risk for falls.

7. Ongoing falls may require relocation from the community.



POLICY: Death of a Resident

The community will take appropriate action in the event of the death of a

resident.

Procedure

1. Call 911. Emergency Medical Services must be summoned to determine

death, unless a hospice nurse is present at the bedside.

2. Do not move the body. The body may not be moved until there is either

coroner release of the body or the police or sheriff on-site gives direct

explicit permission to move the body. Staff should remain with the body at

all times until paramedics arrive.

3. Notify the resident’s primary physician.

4. Notify the Executive Director.

5. The coroner must be contacted. Once paramedics have pronounced the

body (via communication with the physician or coroner), coroner release of

the body must be obtained, allowing for transport to the funeral home of

the resident or family’s choice.

6. Notify the family. Once the body has been pronounced the family may be

told of the death. Frequently the physician will make this phone call.

Otherwise, the Executive Director or the Wellness Director will notify the

family.

7. Prepare the room for visitors if required. Occasionally family or significant

other will want to spend a few moments with the resident prior to transport

out of the community. In consideration, tidy the room, remove linens, etc.,

with objectionable odors and put a chair near the bed. Lights should be

turned on to a comfortable level. Insert the resident’s dentures (if

applicable), close the resident’s mouth and eyes.

8. Contact the funeral home. Once coroner release has been obtained, the

resident may be removed from the community. Call the funeral home



designated. The resident should remain no longer than two hours in the

community, if possible.

9. Document appropriately.

10. Submit a death report to the state licensing agency.



POLICY: Elopement/Missing Resident

Elopement precautions and response procedures are carried out for resident

safety.

Procedure

1. ELOPEMENT DRILLS

a. Elopement drills are conducted a minimum of twice per year and

documented accordingly.

2. MISSING PERSON – GENERAL PROCEDURE

a. Local contact numbers of bus, rail, cab or other modes of

transportation will be maintained for possible contact in emergency

search.

b. Staff shall remain alert and follow re-direction techniques if a

wandering resident gains access to any exit areas.

c. Staff shall request help if wandering resident cannot be redirected

easily.

d. In house transportation staff will be notified of potential elopers

possibly seeking rides and advised to be observant for wandering

confused residents.

e. Staff will be routinely alerted by the Wellness Director of residents

identified to be at risk

f. Service plans will reflect interventions for resident safety

g. Routine safety checks will be made by staff.

h. Flashlights and emergency first aid kits will be included in

emergency supplies to accommodate searches outside

i. Walkie-talkie and cell phones are made available during outside

searches



3. MISSING RESIDENT

a. Staff alerts immediate supervisor to begin a thorough search of

entire community area. This includes searching bathroom areas,

bedroom closets, under beds and window areas to ensure windows

were not used as exit.

b. Executive Director is immediately notified.

c. The Executive Director or designee alerts other departments to

ensure entire community is on alert.

d. A thorough re-search of building including stairwells, roofs,

basements and outdoor area is expanded with ancillary staff and

any volunteers.

e. Automobile searches by staff & volunteers are conducted in

surrounding neighborhood.

f. All search staff call or report back to community regarding status

within 15 minutes.

4. IF RESIDENT IS STILL MISSING

a. Notify sheriff /police department by calling 911 .

b. Provide local law enforcement with the following:

i. Resident full bodied photo

ii. Description of current clothing he/she was wearing

iii. Any other physically identifying information

iv. Information in regard to current medication/treatment needs

v. Information in regard to resident’s nickname or typical

behavior

c. Notify the resident's responsible party.



d. Continue search efforts per direction of law enforcement.

5. MISSING PERSON – IF RESIDENT IS FOUND

a. Notify all searching parties.

b. Conduct assessment to identify possible injuries.

c. Transfer to hospital for further medical evaluation.

d. Notify physician.

e. Notify the resident's responsible party.

f. Complete an incident report and notify licensing agency per

licensing requirement.

6. MISSING PERSON – WHEN RESIDENT RETURNS TO COMMUNITY

a. Obtain updated medical evaluation from hospital or doctors office.

Initiate any new orders.

b. Establish private duty care for resident oversight until resident re-

assessment indicates there is no longer a need.

c. Maintain resident behavior monitoring for identification of any

triggers.

d. Complete resident record documentation.

e. Update service plan and resident summary to reflect potential

elopement.

f. In-service care staff and any relevant staff members.

g. Evaluate the community’s continued ability to meet the resident’s

needs

h. Responsible party will be kept informed and assisted with

alternative placement if determined to be necessary



POLICY: Advance Directives

Residents may have Advance Directives and/or Do-Not-Resuscitate (DNR)

orders. The community staff will take steps to ensure, as best as possible, that a

resident's wishes are honored.

Procedure

1. A Do-Not-Resuscitate order does not direct health professionals working

in the community or any staff member to withhold all emergency care.

The resident should receive all medications, treatments and any other

care as ordered by the physician, as well as all emergency first aid care as

necessary. Any necessary transfer to a higher level of care (acute

hospitalization) should take place as necessary.

2. This policy shall at all times be available for review by the licensing agency

and its representatives.

3. A resident requesting a Do-Not Resuscitate order be implemented will be

directed to obtain the directive from their visiting home health nurse or

physician. No agent or employee of the community shall sign, witness or

be legally recognized as a surrogate decision maker for the resident’s Do

Not-Resuscitate order.

4. A copy of the Do-Not-Resuscitate order will be placed in the resident’s file

and in their room. Note: this is confidential information and must not be

posted in a conspicuous place for visitors or other residents to see.

5. A list of all residents with a current valid Do-Not-Resuscitate order will be

available in the following locations:

a. _____________________________________________________

b. _____________________________________________________



c. _____________________________________________________

6. Should a resident desire, a medic-alert bracelet with a DNR medallion may

be ordered and worn by the resident with a current Do-Not Resuscitate

status.

7. In the event of a crisis, emergency medical services should be

immediately summoned for the resident. When the emergency medical

service personnel arrive they should immediately be presented with the

resident’s Do-Not-Resuscitate order.

DOCUMENTATION AND FORMS




MANUAL

Documentation

and

Forms



POLICY: Confidentiality

All resident data and information is treated as confidential.

Procedure

1. Resident charts, information, preadmission documentation, etc., are kept

inaccessible to visitors and individuals not involved in the direct care and

admission of the resident.

2. Care and administrative staff given access to resident related

documentation are trained during orientation to maintain confidentiality.

3. Photocopying and removal of resident information is strictly prohibited

unless approved by the Executive Director.

4. Release of resident health and personal information is made:

a. When requested by the competent resident.

b. When requested by the resident’s conservator as allowed

according to law.

c. After consent for release of information is signed by either party

above.

5. State regulatory personnel as allowed under regulation may review

resident information.

6. The ombudsman is provided the name of the resident, name and address

of the responsible party and room number of each resident upon request.

7. Medication and other clinical information are provided only upon release

by the resident or conservator, as appropriate.



POLICY: Narrative Charting Entries

Narrative charting will be maintained to promote clear communication regarding

resident care.

Procedure

1. The format for narrative charting is:

a. D = Data

Enter all essential facts related to resident status.

b. A = Action

State the actions/interventions made in response to the data.

c. R = Response

Follow up and document the resident’s response to the action

taken.

2. A narrative entry is made upon admission, noting the date and time of

admission, and any pertinent data regarding the resident’s response to

their placement.

3. A narrative entry addressing current resident status is made every shift (or

more often if necessary) for 48 hours after a fall or sentinel event.

4. Except as stated in (2) and (3) above, staff utilize the charting by

exception related to resident status.

5. The Wellness Director reviews the narrative charting from the previous

shift, for at risk residents.



POLICY: Incident Reports

Injury and unusual incidents will be reported in compliance with state regulatory

requirements.

Procedure

1. The Unusual Incident form is used to document and report any incident

which is a threat to a resident’s health, safety, welfare, or rights. This

includes, but is not limited to occurrences such as:

a. Falls.

b. Injury.

c. Psychiatric crisis.

d. Unexplained absence.

e. Any violation of resident rights.

f. Any incident that threatens the health, welfare, or safety of the

resident.

2. Any incident which is a threat to a resident’s health, safety, welfare, or

right will be reported to the state licensing agency within 7 days of the

incident and a report made via telephone within 24 hours of the incident.

3. The Wellness Director completes incident reports.

4. Incidents are reported to the resident's responsible party. Document the

date and time the report was made to the family/responsible party in the

narrative charting section.

5. All incidents related to physical abuse, neglect, sexual assault, or

exploitation are reported to the ombudsman, state licensing agency, and

in the case of assault (physical or sexual) to law enforcement.



POLICY: Abbreviations

Standardization of terms, definitions, abbreviations, acronyms, and symbols will

be used to promote clear communication and accuracy of information.

Procedure

1. A standardized list of acceptable terms, abbreviations and acronyms is

posted in each community charting area.

2. All staff are instructed to use only approved terms, abbreviations, and

acronyms on this list for all charting.

3. Changes or additions to the list of acceptable terms are made after

approval from the Executive Director and Wellness Director.



POLICY: Approved Abbreviations

ALWAYS follow community policies regarding the use of abbreviations. Never

“invent” a new abbreviation.

Remember, it is best to write words out and avoid the use of abbreviations.

Medical professionals working with Vantage Pointe Village communities should

be encouraged to avoid the use of abbreviations. Never guess at the meaning

of an abbreviation; verify the meaning with the author.

A

a Before

ABD Abdomen

AC Before eating

AD Right dear

ad lib As desired

ADL Activity of daily living

am Morning

amb Ambulate

AS Left ear

ASAP As soon as possible

AU Both ears

B

BID Twice a day

BKA Below the knee amputation

BM Bowel movement

BP or B/P Blood pressure

BPM Beats per minute



BS Bowel or breath sounds

C

c With

C Celsius or centigrade

C&S Culture and sensitivity

CA Cancer

Ca Calcium

CAD Coronary artery disease

CAP Capsule

CAT Computerized axial tomography, as in "CAT scan"

CBC Complete blood count

CBG Capillary blood gas

CCU Clean catch urine

CHF Congestive heart failure

CNA Certified nurse’s aide

CNS Central nervous system

C/O Complaining of

COPD Chronic obstructive pulmonary disease

CPAP Continuous positive airway pressure, as in "CPAP machine"

CPR Cardiopulmonary resuscitation

CSF Cerebrospinal fluid

CT Computerized tomography, as in "CT scan"

CVA Cerebrovascular accident, aka "stroke"

CXR Chest X-ray

D

DAT Diet as tolerated



DC Discontinue or discharge

DM Diabetes mellitus

DNR Do not resuscitate

DME Durable medical equipment

DOB Date of birth

DPT Diphtheria, pertussis, tetanus

DVT Deep venous thrombosis or deep vein thrombosis

DX or Dx Diagnosis

E

ECG Electrocardiogram

ECT Electroconvulsive therapy

ED Executive director

EMS Emergency medical services

ENT Ears, nose, and throat

ETOH Ethanol, often used in reference to alcohol use/abuse

F

F Fahrenheit

FBS Fasting blood sugar

Fe Iron

FTT Failure to thrive

FU Follow-up

FWB Full weight bearing

FWW Front wheeled walker

Fx Fracture

G

GI Gastrointestinal



gr Grain, 1 grain = 65 mg

gm Gram

gt or gtt Drops

GU Genitourinary

H

H Hour

H2O Water

HA Headache

HDL High density lipoprotein

Hgb Hemoglobin

HO History of

HOB Head of bead

HOH Hard of hearing

HR Heart rate

HS At bedtime

HTN Hypertension

Hx History

I

I&O Intake and output

ID Identification

IDDM Insulin dependent diabetes mellitus

IM Intramuscular

INR International Normalized Ratio

IPPB Intermittent positive pressure breathing

IV Intravenous

L



L Left or Liter

LOC Loss of consciousness or level of consciousness

LPN Licensed practical nurse

LVN Licensed vocational nurse, this term is used only in California and

Texas

M

mL Milliliter

MRI Magnetic resonance imaging

MRSA Methicillin resistant staph aureus

MS Multiple sclerosis

N

Na Sodium

NAS No added salt

NG Nasogastric

NKA No known allergies

NKDA No known drug allergies

noc Nighttime

NPO Nothing by mouth

NS Normal saline

NSAID Non-steroidal anti-inflammatory drugs

NT Nasotracheal

N/V Nausea and vomiting

NVD Nausea, vomiting, and diarrhea

O

OD Right eye

OOB Out of bed

OS Left eye



OTC Over-the-counter

OU Both eyes

oz Ounce

P

p After

PC After meals

PDR Physicians' desk reference

pm Afternoon

PO By mouth

PRN As needed

PT Physical therapy or Prothrombin time

Q

Q Every (e.g., Q6H = every 6 hours)

QD Every day

QH Every hour

Q4h, Q6H,

etc...

Every 4 hours, every 6 hours, etc...

QID Four times a day

QNS Quantity not sufficient

QOD Every other day

R

R Right

RBC Red blood cell

RDA Recommended daily allowance

R/O Rule out

ROM Range of motion

RT Respiratory therapy



Rx Treatment

S

s Without

SL Sublingual

SNF Skilled nursing facility

S/O Significant other

SOB Shortness of breath

STAT Immediately

Subq or

SQ

Subcutaneous

Sx Symptoms

T

TB Tuberculosis

Temp Temperature

TIA Transient ischemic attack

TID Three times a day

TO Telephone order

Tx Treatment

U

UA Urinalysis

URI Upper respiratory infection

US Ultrasound

UTI Urinary tract infection

V W X Y Z

VO Verbal order

VRE Vancomycin-resistant enterococcus

WBC White blood cell or count



W/C Wheelchair

WNL Within normal limits

YO Years old

YTD Year to date

Misc.

> Greater than

< Less than

= Equals

# Number, pounds

" Inch or second

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