Senior Housing Management
SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN
Management of the Wellness Center The RN/DWS has the primary responsibility for the management of the Wellness Center and medication management systems within the center. However, audits of Caregiver II and III performance (medication aides) administering medications out of the Wellness Center are a joint responsibility between the facility Assistant Administrator and the Facility RN / Director of Wellness Services (RN/DWS). Daily staffing of assigned / delegated medication administration aides is the responsibility of the Assistant Administrator. Medication administration training, audits, and visual observation of safe performance are a shared task. (See the next page for more specific detail about role differentiation). The RN/DWS works closely with the Assistant Administrator and medication aids to assure all systems related to provision of direct care services are performed in a safe manner. The focus is on the tasks that are directly related to the practice of nursing in community based care as governed by the Oregon State Board of Nursing. The number of points allocated in the care planning process determines the time parameters for this position. These points are based on the actual needs of each individual resident and will vary somewhat over time.
Systems currently in place include the following: Policy and Procedure manuals Resources of information for resident specific care needs Resources for provision of Emergency Care Organization and filing of resident records Communication book Provision of all aspects of Pharmacy services Quality Assurance records for Pharmacy systems Administering and record keeping of TB tests and Hepatitis B vaccines Orientation of staff to care giving Assessment and training of staff for teaching and delegation of specific nursing tasks Routine assessment of the resident’s ability to manage medications Instruction on psychotropic side effects of medication available to all employees Written instruction regarding administration of PRN medications Daily review of all new and/or changes to physician orders Monthly Review of MARs Quarterly review of all Physicians’ orders Review of nursing component of care plan per regulation Provision of nursing tasks of Teaching and Delegation with accurate records. Review of staff performance related to care giving and medication tasks
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SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN
Tools currently in place include: SOPs Pharmacy records Side effects book Order and delivery systems Cycle fill ordering Non cycle fill ordering Narcotic records Non contract pharmacies, list of participants, ordering information Physician orders and MARs Wellness clinic roster and records Pharmacy Quality Assurance Reviews
Role Descriptions ASSISTANT ADMINISTRATOR RN/DWS Manages staff: interviews ,hires Has input into staffing process, including disciplines, rewards, terminates interviewing as requested, emphasis in safe performance of nursing tasks by med aides. Provides general orientation, scheduling Provides orientation to caregiving as requested, lead role in medication management systems, teaching / testing and Delegation Provides general in-service training per Provides training and supervision of all policy, regulation and specific facility need nursing tasks per regulation, OSBN, individual client need and individual caregiver need Gives timely feedback on functioning of all Ensures that all systems are functioning systems within the Wellness Center Supports Wellness Center activity with Leads Wellness Clinic with goal of 100% staffing assistance to reach goal of 100% participation participation by residents Schedules and assures training for Provides training, teaching and Teaching and Delegation do occur delegations, keeps accurate records Ensures new employees are referred for Provides TB testing and Hepatitis B TB testing and are offered Hepatitis B vaccination, keeps accurate records vaccine Ensures all residents have admission TB Provides TB testing to residents, makes test recommendations for follow up if needed, keeps accurate records Follows and has input to monthly Wellness Ensures monthly calendar for all routine Center calendar Wellness Center tasks are provided each month 2of 6 Senior Housing Management
SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN
Suggested Daily Schedule for RN/DWS o Record arrival time on time sheet o Check in-box, visiting professional log book, “Wellness Center communication book” entries since last day you worked o Review ROER’s as referred by “all staff communication book”. Make notation on those that may need your follow up later o Follow-up on any incident reports that have been completed by staff. o Check all new and/or changed orders since last day you worked o Check monthly calendar for things that must get done today (example; lab tests) o Write “To Do List” based on priorities for the day o “Walk around,” observing staff and resident interaction for possible needs o Touch bases with medication aid/ management for possible needs o Audit MAR’s for completion. o Ensure cross referencing of old and new MAR’s and related audit follow- ups are completed o Continue with “To Do” list until it’s time to go home o Record end of shift time (including lunch) on time sheet.
Management of Nursing Tasks on a Daily Basis What tasks require your direct intervention and which can you rely upon your staff to perform? The answer to that will depend in a large part on how well you have trained your staff and what you are personally accountable for. Intervention strategies are determined by whether health events that occur represent short term changes of condition or whether the health event represents a significant change of health status requiring a nursing assessment with ongoing nursing intervention. Examples of nursing tasks: The RN/DWS has taught the task of Administration of non-injectable medications. The staff will perform the task, but only you are capable of reviewing the data and assessing the resident’s overall response to treatment. You will assess the response to a PRN order by reviewing the dose patterns and the responses on the MARs. The RN/DWS will review the documentation (of observations made by unlicensed staff providing treatment to a rash), but only the RN/DWS may visually assess the response to treatment (and healing progress) including documenting when the event is “resolved”. The RN/DWS may delegate some aspects of wound care, but only the RN/DWS may visually assess the status of that wound and the need for home health involvement if the wound represents a significant change in health status.
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SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN The RN/DWS may train the staff to notify you of any possible side effect of a psychotropic medication, but the RN/DWS is responsible for review of the medication regime and assessment of the resident s response to the entire situation which has environmental and psychosocial contributors as well as the actual medication. The RN/DWS may receive a physician’s directive stating that the resident is capable of self medication, but it is the responsibility of the RN/DWS to personally assess and document their ability. A period of further evaluation or a change in directives may be indicated. The RN/DWS writes the care plan for behavior interventions prior to the administration of a PRN psychotropic medication (Alternate Measures Flow Sheet). It is also the responsibility of the RN/DWS to assure the plan is followed and changed if necessary. The RN/DWS delegates a caregiver to perform specific tasks or teach care staff the administration of non-injectable medications. It is the responsibility of the RN/DWS to review the performance of, and the response to, those tasks in a timely manner.
The Role of the RN/DWS in Assessment and Care Planning
The Executive Director is trained and assigned the responsibility of coordinating information and performing the Care Plan of the resident with the assistance of our software.
The goal of this Care Plan is providing mutually agreed upon services to enable the resident to choose an environment and lifestyle which maximizes their quality of life. The RN/DWS will review and sign all service plans, and propose changes as needed on an on-going basis.
It is imperative to consider residential care as a lifestyle choice of which the medical component of that life is only a part. Granted, for the RN/DWS, it is the major part of his/her responsibility to his/her license and his/her clinical role in assuming and delegating authority and responsibility. How can we comfortably achieve the balance necessary?
Role 1. We must fully understand the services and type of residents to whom we may provide services in a specific location and for a specific corporation or owner. It may vary with changes in regulations, market niche, staffing circumstances, or the life cycle of the business.
2. We must balance our clinical role with management’s role in maximizing the autonomy of the resident and family unit, recognizing reasonable risk, clearly defining risks, responsibility and accountability.
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SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN 3. The RN/DWS must recognize her role as not the principal caregiver, but the person who assists the resident to receive services from the most appropriate provider. In this role the RN/DWS acts as the resident advocate rather than the direct service provider.
Process 1. As with any assessment, accurate data gathering is the first step. The Executive Director interviews the resident and /or responsible party, obtaining financial, social and medical information, which indicates a probable “fit” with the community.
2. Next, it is the resident/ family’s responsibility to obtain a complete history and physical examination from the physician. Included in this must be a complete list of current medications, a diet recommendation, a statement of the resident’s ability to manage medications, and the results of a TB test or an order to administer one per state regulations.
3. The Executive Director receives this information and reviews it PRIOR to approval of the move in. It is shared with the Assistant Administrator and the RN/DWS so that each one may use his/her skills to identify strengths and potential problems that must be addressed prior to move in. Some common problems include lack of accuracy and completeness of information. Not all physicians, medications, allergies, or care needs may be identified. Often a family member must contact the provider or other providers for additional information. Perhaps a diagnosis or the name of a medication may indicate a new consideration that had not been previously noted. (diabetes, incontinence, psychological problems) Once all information has been received, reviewed and provided to the team, the manager meets with the resident/family to complete the agreed upon care plan and the move in takes place.
4. The preferred time frame is that all the physician’s orders would have been transcribed and all the medications will have been delivered prior to move in. Reality often dictates that this process is concurrent with move in and may be not a smooth as desired. Be ready for all possibilities while wearing your brightest smile. This is a stressful time for the family and resident who often do not understand our bureaucratic needs.
5. If we are assisting with medications it is essential that all information and supplies be accurate and available prior to beginning the service. The RN/DWS or a trained staff member must review all orders and medications for accuracy. No medication is to be given without an order that is signed and dated by a physician. Any discrepancy in orders or labels must be clarified prior to administration.
6. It has already been established in the care plan whether or not the resident may manage medications. Regardless of that determination, it is the responsibility of the RN/DWS to interview the resident in his/her apartment and review all medications while assessing the person’s mental and physical ability to perform or direct that task. Having the resident bring all containers to the table and using the form 5of 6 Senior Housing Management
SOP # N115 Revision 3 Effective Date: 11-16-07 Prepared by: DCH Approved By: CAM Title: The Role of the RN provided by facility’s pharmacy will assist in the process. If additional aides (medi- set, reminders) are needed or a change in the care plan is indicated, it should be brought to the attention of the Executive Director immediately.
7. This is also a good time for the RN/DWS to perform a professional, but discreet assessment on the resident’s ability to function in the apartment, observe the condition of the apartment for safety and equipment needs. Perhaps there are mobility issues that were not evident earlier, or orthopedic devices may need to be included in instructions for care.
8. Extend an invitation and explain the role of the wellness clinic to the resident. Our goal is 100% participation in that program and is one more opportunity to monitor those appropriate services are provided.
9. Changes in condition, physician’s orders and services provided are communicated by all staff on ROERs as the need occurs. This is also the primary tool for the RN/DWS to communicate with management. It is essential that all changes be communicated to management in a timely manner so care plans may be changed as needed.
10.The RN/DWS will also meet with the Executive Director & Assistant Administrator weekly and review the “Weekly RN/DWS Report. Training and staffing needs may also be addressed at this time to ensure changes in care needs are addressed accurately. This should be a regularly established time each week. A copy of the Report will be kept both by the RN/DWS and the Executive Director as a Quality Improvement tool.
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