Transcript Besides Xanax, what is the CNP`s role in the survery process

Besides Xanax, What is the CNP’s
Role in the Survey Process
• The survey process is probably one of the
most stressful times for the nursing home
staff. Most facilities attempt to manage
the process as much as possible, however
there are ingrained processes that they
must follow in the survey.
The CNP roles begins prior to the
actual survey
• Always ensure that the documentation is
complete and clear and concise.
• It goes without sayings, I am sure, but
ensure that there are no departmental
battles in your notes. This will send red
flags out to the surveyors.
General Survey Protocol
• Every facility is different in how they
manage the process, however it is
common practice not to provide any
copies of information to the surveyor
directly. The surveyor should be directed
to request information from the
Administrator or DON.
• It is wise to have a witness with you if
asked to speak with the surveyor.
• Only answer the question asked, do not
provide additional information.
CNP/MD visits
• Residents are required to be seen by the
doctor every 30 days for the first 90 days.
It is recommended that the visits alternate
between the CNP and MD.
• They must be seen every 60 days after.
• A visit is timely if it is within 10 days after
the due date.
Quality Measures
• All nursing homes are rated based on
Quality Measures. These are broken down
between long term care and short term
residents. For the long term residents,
the following are the items looked at:
• The percentage of residents experiencing
one or more falls with a major injury
• Percent of long-stay residents with UTI
• Percent of long-stay residents who self-
report moderate to severe pain.
• Percent of long-stay residents with
pressure ulcers
• Percent of long-stay residents who lose
control of their bowels or bladder.
• Percent of long-stay residents who
have/had a catheter inserted and left.
• Percent of long-stay residents who were
physically restrained
• Percent of long-stay residents whose
need for help with daily activities has
increased.
• Percent of long-stay residents who lose
too much weight.
• Percent of long-stay resident who have
depressive symptoms
• Percent of long-stay residents assessed
and given, appropriately the seasonal
influenza vaccine.
• Percent of long-stay residents assessed
and given, appropriately, the
pneumococcal vaccine
• Percent of long-stay residents who are
administered antipsychotic medications.
Short-Stay Residents
• Percentage of short-stay resident who
self-report moderate to severe pain
• Percentage of short-stay residents who
new or worsening Stage II to Stage IV
pressure ulcers
• Percentage of short-stay residents
assessed and given, appropriately, the
seasonal influenza vaccine.
• The percentage of short-stay residents
assessed and given, appropriately, the
pneumococcal vaccine
• The percentage of short-stay residents
who are newly administered antipsychotic
medications.
• Based on these measure, we can
obviously control some of them, however,
not all. Most facilities try to manage these
situations as much as possible, however
there are always situations we cannot
control. This is when the ongoing
documentation to “prove” the actual
situation becomes vital.
Falls
• We would all love to have a “fall free
facility”, however that is impossible. This
is why we need to review each fall on an
ongoing basis and add some type of
interventions. It truly takes a team
approach to be as creative as we need to
with interventions related to fall. It is
important as well, to rule out medical
issues.
Urinary Tract Infections
• Again, we really cannot control this area
100% !
• As the CNP, you need to ensure that
treatment is rendered as needed and
appropriate and that for the resident with
frequent UTI’s all appropriate
interventions are in place.
• Educate residents, families and staff.
Pain Management
• This is always a challenging area to ensure
that triggers do not occur. We all have
the resident who will smile, show
absolutely no s/s of pain, but will rate
their pain at 9 – 10. We basically need to
show that we are attempting to assess
and address the pain, and again educate
residents on pain and document.
Loss of Bowel or Bladder Control
• Again, we wish we could control ones muscle
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control, however…….
This is related to low risk residents who do not
have severe memory losses and/or severe
limitations in mobility
We always need the appropriate documentation
to explain why declines have occurred and to
show that we have made all appropriate
referrals and attempts to control what we can.
Catheters
• I certainly don’t need to tell you about the risks
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related to catheters!
The CNP/MD need to ensure that all attempts
have been made to discontinue the use of a
catheter. If unable, we need to show that the
urologist was involved, that appropriate
medications were attempted and that the
appropriate diagnosis is in place.
Appropriate Diagnoses
• Obstructive uropathy
• Neurogenic bladder
• Treatment of stage III or IV pressure ulcer
for an incontinent resident.
Physical Restraints
• Most facilities refuse to use any physical
restraints.
• If there is a situation where a restraint is
used, please ensure that there is
appropriate documentation to justify the
temporary use of and removal of the
restraints.
ADL’s
• Obviously, the need for assistance with ADL’s is
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one of the main reasons residents are admitted
to facilities. When a resident needs more
assistance with eating, transferring, changing
position in bed and toileting, our quality
measures change.
We need to ensure that we are doing everything
possible to maintain their level of functioning
with either therapy referrals or restorative
nursing programs.
• If there is a sudden decline in ones
abilities, is there a medical reason for this
which obviously needs addressed.
• If there is a slow steady decline, it may be
the normal aging process.
• Or, there may be a temporary decline
related to an acute medical situation.
• DOCUMENT WHAT YOU FIND
Weight Loss
• Obviously with weight loss, the CNP will
work closely with the facility Dietician to
ensure all appropriate interventions are in
place to prevent weight loss.
• Rule out medical issues that could be
associated with the weight loss.
• Document
Influenza and Pneumococcal
Vaccines
• The primary role of the CNP in this area is
education of residents and family to
encourage the use of the vaccines. Again,
it certainly does not hurt to document the
reasons for the refusals, however this area
is basically documented in numbers.
Depressive Symptoms
• This is a very difficult area. On one end of the
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spectrum, a facility get reimbursed more for
residents with s/s of depression being present.
We all know that with all of life losses that our
residents are facing, depression is very
prevalent.
This measure monitors the increase in signs and
symptoms, therefore the appropriateness of
treatment is very important.
• Most social workers will notify the CNP/MD
of significant scored on the PHQ9. This is
the assessment we use for mood.
• We need to show that we have made
attempts both non-pharmacy related and
pharmaceutical as needed.
• We need to show the team approach to
attempts at treatment and again the
appropriate documentation needs to be in
place.
Psychoactive Medications
• The nursing facility is mandated to
decrease the use of psychoactive
medications by 25% by the end of 2015
and by 30% by the end of 2016.
• This being said, we also have behaviors
that need to be treated. The goal is to
reduce the use of medication with the
black box warning.
Each resident’s drug regimen must be free from unnecessary drugs. An
unnecessary drug is any drug when used:
• (i) In excessive dose (including duplicate
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therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring
(iv) Without adequate indications for its
use; or
(v) In the presence of adverse
consequences which indicate the dose
should be reduced or discontinued
That is great but…….
• The CNP need to monitor PRN meds and
discontinue when they are not needed.
• Consult with the MD about the
medications and document the effects.
• If a dose reduction is attempted and is not
successful, you need to ensure that there
is adequate documentation to justify
failure of the attempted reduction.
Pressure Ulcers
• Ensure that your notes indicate that the
ulcer/s are unavoidable.
• You are encouraged to document all
known attempts at avoiding the
development of ulcers as well as noncompliance on the part of the residents.