Revise Policy PLan

Name, Title & Date

341 Page

cos:r OF RESIDENTIAL SERVICES

Patients and Patient's representatives will be provided with:

a) Statement of liability for cost of services not covered by the Patient's insurance company, for Residential Services;

b) A Step Above All Health Services process for presenting itemized billing statement es-timate of costs associated with Residential Services Requested;

c) Estimate of costs associated with the services requested by Patients or Patients' repre-

sentatives.

Statement of liability for cost of services not covered by the insurance company.

Prior to the start of Residential Services, A Step Above All Health Services will provide the Patient or Patient's representatives with hourly rate of our services, in writing when the Residential Service required is a private pay case.

Patients will receive billing weekly and are expected to pay for services on a weekly or bi-weekly basis. If Residential Services requested by the patient is not covered by the insurance; A Step Above All Health Services will provide the Patient with an itemized invoice as shown below:

SAMPLE ITEMIZED BILL ON NEXT PAGE

�

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SAM_PLE ITEMIZED BILL

A Step Above All Heahh Services

5002 Hollington Dr. #302 Owings Mills, Maryland 21117

'li:(143) 803-3285 Email Address: Shazata32@gmail.com

BILLING DATE: - 02/12/2016

SERVICES PROVIDED: PERSONAL CARE SERVICES

PATIENT'S NAME MS. JASMINE SMITH

84 Franklin Square Drive Baltimore MD. 21236

Total Hours worked 42h

TOTAL DUE FOR Residential Services from 01/31/2016 - 02/06/2016 $756.00

With th?cnks, A Step Above All Health Services will receive payment for Residential Seryices render<cddue dateli11·1<cceipt of Payment is 02/20/2016. Please note that payments not received after two weeks of invoicing will result in discontinuation of �ITvices.

.--

361 Page

INVOICING - MAINTENANCE OF CHARGES

}'atients R�ECEIVING Residential services from A Step Above All Health Services� will be invoiced on a weekl,)7: basis.

Our Agency will bill Clients on a weekly basis. We expect all Patients to pay for Residential

services within 2weeks after receiving the bill.

The Nurse's initial assessment will be offered to all Clients free of charge.

All Clients have the right to receive to an itemized bill, including date of services and visit charges for all services they have received.

All payments are noted. The Client will receive a receipt and Our Agency will keep a copy of the receipt issued to the Client on file at the Agency address.

- PRIVATE PAY CLIENT

Before A Step Above All Health Services starts to provide Residential Services for a Client, we will inform the Client of the rate per hour of our services, in writing.

We will establish a special rate for Clients who cannot afford to pay for Residential services at Our Agency's hourly rate. This will allow these patients, who cannot pay at the fixed rate to also have some assistance with activities of daily living in their residence.

All other Clients will pay for Our services at the agreed upon rate before Residential services starts. The Nurse's initial assessment will be offered to all Clients free of charge. All Clients have the right to receive to an itemized bill, including date of services and visit charges for all services they have received.

A Step Above All Health Services will bill Clients on a weekly basis. We expect the Client to pay for Residential services provided by our Agency, within 2weeks after receiving the bill.

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All payments are noted. The Client will receive a receipt and Our Agency will keep a copy of the receipt issued to the Client on file.

A Step Above All Health Services will accept payments in check for Residential services provided to all Private Pay Patients.

· MEDICAID WAIVER CLIENT'S PAYMENT PROCEDURE

A Step Above All Health Services bills for all Medicaid patients on a weekly basis. Billings are prepared on the Medicaid billing form, to include the date of services, units of services-hours worked, the patient's name, Medicaid number and our agency provider number.

A Step Above All Health Services does not accept any form of payments from Medicaid recipients.

All staff of A Step Above All Health Services working in the homes of Medicaid Waiver recipients are informed in writing that they are strictly prohibited to receive money or gifts from their Patients in exchange for services that they have been called to provide for the Patient under our Agency.

Any staff found to have violated this rules in any way, will be replaced with immediate effect. A Step Above All Health Services will accept payments in check for Residential services provided to all Patients. Cash are not accepted for payment.

All billings for services provided to Medicaid recipients are forwarded to the Medicaid Waiver Coordinator, 3 10 West Preston street, Baltimore Maryland 2120 I.

························••.!.••·························

38!Page

A STEP ABOVE ALL HEALTH SERVICES

QUALITY ASSURANCE PROGRAM

Policy:

A Step Above All Health Services is dedicated to continuously making every effort in improving the quality of health care and services delivered to all patients served. We will develop at least one committee that will oversee quality assurance activities, provide minutes, reports and correspondence that will be related to the Quality Assurance activities.

Our Quality Assurance Team includes the 1 Patient, 1 Patient family member, Administrator, the Director of Nursing, 2 LPN's, 1 nursing assistant and 1 Board member.

Procedure

A Step Above All Health Services will evaluate the need to develop a staff performance improvement team needed to assist in the improvement of our health care services.

Quality Assurance Team

A Step Above All Health Services Quality Improvement team will meet on the last Saturday of each month to review negative patient's evaluations and / or complaints.

Their responsibilities will be to handle implementation of new policies and procedures in improving health care services and patient's satisfaction in its delivery.

A Step Above All Health Services' Director of Nursing will be responsible for the quality assurance reviews. Our Agency will collaborate with fellow patients and their family members to receive feedback and suggestions, in the delivery of their health care services.

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We will utilize Patient's feedback to modify or implement new techniques that will embrace improved delivery system.

Every year the management of A Step Above All Health Services will meet to evaluate the entire quality assurance program. At that point, the strengths of the program will be highlighted, while the weaknesses of the program will be addressed.

Patients/representatives input

Patients/representatives will be given a client's satisfaction survey every month; to give A Step Above All Health Services their overall perception of the quality of services they received. We will welcome any suggestions to improve our overall health care service delivery in patient's care.

Patients and their family members participating in A Step Above All Health Services client's satisfaction survey will have the option of being anonymous; affording every opportunity for them to feel comfortable in expressing their views.

The data collected from such surveys will be thoroughly reviewed and assessed; to determine what might be implemented to improve care.

Nursing: Staff Input

In an efiort to continuously improve the quality of health care delivery; on December of each year; A Step Above All Health Services Administrator will perform an annual evaluation of all staff Data from the clients will be used in this evaluation; as well as feedback from our nursing staff and their supervisors.

At the end of the process, there will be a one on one meeting between staff, Administrator and Supervisor. Staff will be ranked as Outstanding, Good and Needs Improvement.

Outstanding staff will be considered for greater compensation and staff needing improvements will be trained in the areas where they might need improvement and support. The end result will be to have a productive staff body that will produce the best quality of health care service to all patients the will be served through A Step Above All Health Services.

The Director of Nursing will ensure that all staff is current on their licenses/certification; training/ re-training; and will ensure that all license and certification be completed prior to expiration dates.

A Step Above All Health Services Director of Nursing will keep copies of all licenses for the licensed staff; and ensure that all licenses are renewed and all continuous education training is completed by the staff. All records of such will be maintained in a safe and confidently compartment at our agency address, and will be readily made available for responsible Department's review.

QUALITY ASSURANCE MECHANISM

To ensure that all functions are performed safely and patients' outcomes meet accepted professional nursing standards, our services have a quality assurance mechanism in place to include:

a) An ongoing formalized documented performance appraisal mechanism will

be designed by A Step Above All Health Services; to assure that unlicensed individual or certified nursing assistant's revalidation of continued competency is a component of the quality assurance program; and

b) Client outcomes meet accepted professional standards, as reflected by:

(i) Infection rates;

(ii) Rates of adverse events;

(iii) Error rates; and

(iv) Patient satisfaction surveys.

(v) Grievances and complaints.

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MONTHLY _QUALITY IMPROVEMENT COMMITTEE MEETING

Location: Date:

Time: ----

Names of Attendees Present

Administrator []Yes[] No

Director of Nursing [] Yes O No

If no, give reason: _ If no, give reason: _

Board Member [] Yes [] No

If no, give reason: _

Report from the Administrator on the realization of last month's immediate actions (attached additional sheets if needed):

Monthly Report from the Director of Nursing (attach additional sheets if needed):

Monthly Report from the case monitor (attach additional sheets if needed):

Monthly Report from the LPNs (attach additional sheets if needed):

Monthly Report from the Nursing Aides (attach additional sheets if needed):

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Board reactions (attach additional sheets if needed):

Discussions of the issues with provision of service (attach additional sheets if needed):

Recommendations on the way forward (attach additional sheets if needed):

Concluding statements by the Administrator (attach additional sheets if needed):

Immediate actions to be taken to improve the quality of service:

Name & Signature, Quality Improvement Chair Date

Signature, Quality Improvement Co-Chair Date

44

A STEP ABOVE ALL HEALTH SERVICES CLINICAL MANAGEMENT POLICY

For Patients and staff record privacy; A Step Above All Health Services has a policy in place, that is designed to ensure that all clients/patients will receive care and services that will promote and maintain their health, safety and dignity.

We will provide specialized skilled services in accordance with regulations and standards that meet and exceed requirements.

A Step Above All Health Services will ensure that all clients/patients care is preserved and maintain in a locked cabinet at our agency address to include:

· Primary Care Physician orders for care, diagnoses, medications, treatments, frequency of visits, be documented in all clients' files.

· Documentation and record keeping

· Documentation of services

· Patient assessment

· Personalized plan of care

· Coordination and collaboration on care and services

· Supervisory visits and skill assessment

· Training and. orientation of clients/patients, stafi; and personnel

· Physicians medication order form (PMOF) completed and signed for all medications and treatments being administered by agency's staff

A Step Above All Health Services has a policy to address verbal orders, nursmg assessments for both skilled and aide only patients.

We will have and follow the procedure for Medication Administration Record (MARS) and Treatment Administration Records documentation by the authorized personnel who is administering the medications.

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We will ensure that such policies cover complex nursing services to include policies and procedures for Tube Feeding, Pain Management, Wound Management, Trac Management, IV Therapy, and Ventilator Services.

A Step Above All Health Services will include services to provide for the needs of all client/patients as it is required and prescribed by the patient's primary care physician and in adherence to client's service plan and contract/ agreement.

A Step Above All Health Services will:

1) Ensure that qualified staff is on hand, with a stand by staff to be available through contractual arrangements to provide the feeding services prescribed by the patient's physician.

2) Ensure that all skilled care services are provided in compliance with the Maryland COMAR regulations and all applicable sections of Health Occupations Article, Annotated Code of Maryland.

To accomplish our goals for this requirement, A Step Above All Health Services will maintain its policy to provide each patient with the best quality of care available to meet all their medical needs.

46

PERSONNEL - JOB DESCRIPTIONS FOR ALL POSITIONS

Director of Nursing

A Step Above All Health Services Director of Nursing is responsible for the operational, management and supervision of the organization, including the coordination of patients' care, and evaluation of all professional and clinical staff.

Our director of nursing ensures that all clinical staff have the skills and qualifications required by Federal, State, and Local regulatory bodies, including the Nursing Practice Act. In addition, our health services Director of Nursing ensures and enforces the following:

· that quality and appropriate care is provided to all patients;

· provision of directions to team, supervisory, and support staff; and,

· acting as clinical liaison between the agency and other health facilities, and patients.

A Step Above All Health Services director of nursing is also responsible for assessing, planning, initiating, coordinating, monitoring, and evaluating patient care activities, to include:

· overseemg of clinical nursing practice, utilization of area resources, and operations in accordance with DHMH and all licensing requirements.

· functioning within and supporting the philosophy and mission of A Step Above All Health Services.

· being responsible and accountable for the operational management, leadership, professional development and quality assessment and improvement activities.

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· being responsible for patient care management for the Agency and its clients.

· performing supervisory visits on clients and staff

· conducting initial assessment of all bodily systems with complete documentation.

· reviewing of all patients' plan of care for accuracy and important updates.

· providing adequate and up to date supervision and training of all nursing staff

· planning, implementing, conducting and overseeing the orientation of new nursing staff

· following-up and ensuring the conformance to all physicians' orders.

· keeping abreast of new trends, tools, and procedures in the professional nursing environments, and,

· maintaining skills competencies for all nursing staff; and ensuring that the demonstration of skills competency has been observed, documented, and verified by the signature of the RN supervisor or Registered Nurse.

As determined by the Maryland State Board of Nursing under the licensing requirements for Registered Nurses, A Step Above All Health Services Director of Nursing must have acquired at least two years' experience as a clinical nurse.

A Step Above All Health Services Director of Nursing ensures that all employees provide our agency with the following documentation:

· Medical evaluation to ascertain that they are free from infectious diseases and are physically able to perform job functions.

· Annual TB screening (if tested positive for PPD), but is subsequently cleared fit

by follow-up testing procedures.

· Provide at least two professional references.

48

· Show original and current state licenses, CPR certification, and other practice and work authorization documents.

· Undergo and pass a criminal background check through Maryland Department of public Safety and correctional services-CJIS.

· Provide extensive documentation of proof for clinical and specialty care.

A Step Above All Health Services director of nursing must be a Registered Nurse, and/or hold a Bachelor of Science degree in nursing (BSN); and who holds a current and active CPR and First Aid certifications.

Our Health Services administrator must also hold competent computer skills, needed to adequately manage the agency's daily operations.

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REGISTERED NURSE

All registered nurses who will work with A Step Above All Health Services will directly report to the Director of Nursing.

Registered nurse provides skilled nursing care to clients as prescribed by the physician and in compliance with patient's plan of care.

RN works under the supervision of the director of Nursing in the planning and delivery of clients' care.

A Step Above All Health Services RN's duties shall reflect the highest standards of nursing practice, and shall be proactive and reactive to clients' needs. Such functions shall be undertaken in a manner as to promote qualitative, continuity, well-being and safety of all patients served.

The licensed RN would be assigned tasks that require nursing skills and the professional judgments of a registered nurse.

The RN will:

· ensure that appropriate and qualitative care is provided to all patients.

· ensure that all clinical staff have the skills and qualifications as required by DHMH RSA licensure department.

A Step Above All Health Services director of nursing is the immediate supervisor of the RN. The DON carries out evaluation of the RN at least every 30 days.

When on assignment, the RN must follow the reporting relationship as outlined by the Health Services policy.

50

Additional ResponsibilitieJ!

RN must implement orders for medications and treatments as prescribed by the physician, in the medical plan of treatment.

RN supervises the clinical duties of an LPN and CNA.

Qualifications - Employment Requirement for RN

· Graduate from an accredited nursing program.

· Current RN licensure granted by the Maryland Board of Nursing.

· Current and Valid CPR certification

· At least 1-2 years' experience working in home care setting.

· RN must be able to meet the physical and mental requirement of the position.

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LICENSED PRACTICAL NURSE

A Step Above All Health Services licensed practical nurse provides skilled nursing care to patients as prescribed by the patient's primary care physician and under the supervision of a Registered nurse, in the planning and delivery of patient's care.

A Step Above All Health Services assignment of the LPN to patients reflects the highest standards of nursing practice, and is both proactive and reactive to the need of the patients. This assignment is provided in a manner consistent with the promotion of quality, continuity, and safety needs of patients.

The LPN may be assigned to give nursing care that does not require the skill and/ or judgment of a registered nurse.

When assigned to a patient's care, the LPN will:

· ensure that appropriateness in the quality of care provided to all patients.

· follow the reporting relationship as outlined by A Step Above All Health Services' policy.

Job Requirements & Qualifications:

Before an offer of employment is made, the LPN candidate must be

a) A graduate of an accredited school of nursing.

b) Must possess current valid CPR certification.

c) Be currently licensed in good standing by the State board of nursing.

d) Must have at least one-year experience as a LPN.

e) Must meet the physical requirements of the position.

f) Must have direct pediatric care experience within the last two years.

52

Other requirements include:

· Completion of an application packet.

· Furnish A Step Above All Health Services with at least two professional references.

· Show evidence of US citizenship or legal residency, and work authorization.

Copies of all legal documents, including social security cards, driver's license, etc. would be made at our agency address and kept in the employee file.

· LPN candidates must undergo and pass a criminal background check conducted

CJIS.

· LPN MAY NOT admit patients

· LPN is supervised by RN no less frequently than every six visits or two weeks, whichever comes first.

Responsibilities of A Step Above All Health Services Licensed Practical Nurse: Provides first aid and emergency care to Patients according to the Maryland Nurse Practice Act

Carries out nursing tasks by the authorized prescribers' orders

Maintains appropriate professional development necessary to provide safe and pro-fessional care to Patients

Assists RN Supervising LPN to assure patient's health record is accurate and up-

to-date as determined by federal, state, and local laws and regulations

Carries out health services procedures as determined by the physician's orders and within the constraints of their licensure,

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Observes patients' health for any pertinent negative results

Maintains accurate, confidential and appropriate records following all established procedures

Communicates necessary medical information in a timely manner to Supervising

RN while maintaining confidentiality

In collaboration with the Supervising RN, participates in patient's team meetings Maintains adequate supplies

Monitors and reports environmental concerns, and health and safety issues to reg-istered nurse supervisor.

Licensed Practical Nurse

A Step Above All Health Services Licensed Practical Nurses are licensed through the Maryland Board of Nursing as LPN and work under the supervision of a Registered Nurse Supervisor.

A Step Above All Health Services licensed practical nurses care for patients in the following ways:

· Measure and record patients' vital signs such as weight, height, temperature, blood pressure, pulse, and respiratory rate.

· Prepare and give injections and enemas,

· Monitor catheters,

· Wound dressing,

· Administer prescribed medicines

· Start intravenous fluids

· Provide care to ventilator dependent Patients

· Give alcohol rubs and massages.

· Collect samples for testing,

54

· Perform routine laboratory tests,

· Record food and fluid intake and output.

· Clean and monitor medical equipment.

· Assist physicians and registered nurses perform tests and procedures.

· Help to deliver, care for, and feed infants.

· Monitor patients and report adverse reactions to medications or treatments.

· Gather information from patients, including their health history and how they are currently feeling, and provide the information to registered nurses and doctors to help determine the best course of care for a patient.

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JOB DESCRIPTION OF A MEDICATION TECHNICIAN

· ADMINISTRATION OF DRUGS, only MEDICATION TECHNICIAN;

· MED TECH MUST INFORM AGENCY NURSE SUPERVISOR &

PATIENT'S PERSONAL PHYSICIAN OF ALL MEDICATION ERRORS;

· Sl{ILLS ASSESSMENT WILL BE CONDUCTED UNDER THE SUPERVI-SION OF A RN-SUPERVISOR;

· NURSE SUPERVISOR WILL VISIT PATIENTS HOME MONTHLY AND EVERY TIME MEDICATION CHANGES; TO ENSURE PROPER MEDICA-TION MANAGEMENT BY MEDICATION TECHNICIAN.

ADDITIONAL JOB RESPONSIBILITIES OF MEDICATION TECHNICIAN".

In addition to administering Medications. MED TECH will perform the following tasks at the Patient's home:

· LIGHT HOUSE I{EEPING

· MEAL PLANNING & PREPARATION

· SHOPPING & ERRANDS

· PERSONAL HYGIENE

· TOILETING

· DRESSING

· COMPANIONSHIP

· AMBULATION.

Medication Technicians to include all the above listed nursing assistant functions, plus medication administration under the supervision of a registered Nurse.

56

CERTIFIED NURSING ASSISTANT /HOME HEALTH AIDES

A Step Above All Health Services Certified Nursing Assistant will provide personal care services, under the direct supervision of a registered nurse.

These tasks include assistance with activities of daily living; companionship and other related supportive tasks, as indicated in the patient's plan of care.

· Certified Nursing Assistants will be assigned to patients for routine daily personal assistance with activities of daily living as may be directed and planned by the RN, in collaboration with the patient and/ or the family representatives.

· Introduces self to client and proceed to perform daily care routines as required by patient's plan of care: e.g. bath, dress, assist in toileting, transferring the client to and fi·om a wheel chair or bed and perform light housekeeping.

· Based on clients' needs and doctor's order, may assist registered nurse during dressing change or remind and observe patient, if the client can medicate himself/herself

· Prepare meals from patient and may feed patient where needed.

· Take inventory of food and housekeeping supplies and may go to nearby market to purchase required food and supply items with funds supplied by patient.

Leaves accurate receipt and accounts for all monies of purchase.

· Follows safe lifting practices in lifting client from and to wheel chair.

· Provides adequate follow-up care sequentially like assistance to Doctor's office, or community activities of interest to the patient.

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· Provide adequate information to the Registered nurse and document all care records appropriately.

· Must express cheerful, 'upbeat' disposition which will provide positive atmosphere for client.

· Must accommodate client's need through responding appropriately to client's

verbal/nonverbal expressions of need.

· Always maintain client's self-esteem and confidentiality of personal information.

Qualifications:

CNA must have successfully completed the Classroom component of an approved State Certified CNA Training Program which includes demonstration of competencies in basic skills.

· Able to adequately demonstrate skill review.

· An approved CNA course certificate from Maryland Board of Nursing.

· One year of CNA experience is preferred.

· Current/ Unrestricted CNA certification.

· Meet physical requirement of the CNA position, and complete A Step Above All Health Services' application

· Furnish the agency with at least two professional references

58

· Show evidence of US citizenship or legal residency, and work authorization.

Copies of all legal documents, including social security cards, driver's license, would be made at our agency address and kept on the employee file.

· CNA candidate must undergo and pass a criminal background check conducted by CJIS

Reporting Relationship:

The CNA is observed and supervised by RN. The RN supervisor observes the CNA at least every 30 days.

Prior to providing care to patients, RN looks into CNA personnel file to include:

· Health requirement for all CNA: medical exam verifying they are free from infectious diseases and are physically fit to perform their job functions.

· An annual TB screening for negative results

· If there is a history of positive PPD, chest X-ray to determine that the CNA is free from the disease would be required and also be able to lift and bend.

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OFFICE MANAGER/STAFFING COORDINATOR

A Step Above All Health Services Office Manager / Staffing Coordinator is responsible for assisting the Administrator in the financial planning and analytical review of agency operations as they relate to billing, salaries and wages, office administration, tax and financial planning, and stafiing coordinating functions.

Res.P.011si_bilities:

The Ofiice manager/ stafiing coordinator, under the direct superv1s1on of the Administrator and the registered nurse supervisor will oversee the day-to-day stafiing functions and clerical activities of the Agency.

A Step Above All Health Services Office Manager / Staffing Coordinator interacts with all levels of agency staff In collaboration with the Registered Nurse Supervisor, he provides support and leadership to new and existing nursing staff

Personnel will perform a range of basic office support duties for the agency, such as answering phones and directing calls, staffing coordinating functions, answering questions, providing information to new and prospective clients on services that A Step Above All Health Services provides and performing routine clerical, data entry, and word processing functions as assigned.

MUST PRESERVE patient and staff privacy of records.

60

Knowledge, Skills, and Abilities (KSA):

· Record maintenance skills

· Word processing and/ or data entry skills

· Receptionist skills

· Ability to understand and follow specific instructions and procedures

· Ability to prepare and print routine correspondence, labels, and/or other basic written materials

· Demonstrated skills in the use of basic office equipment

· Ability to maintain calendars and schedule appointments.

Pre-employment Requirements: He must be able to produce legal authority to work in the US, undergo and pass a criminal background check through CJIS, provide at least two completed professional references, provide proof of education and training, and demonstrate the ability to perform the above listed duties.

COPIES OF RN, LPN, MT, CNA LICENSURE ON NEXT PAGE

-Or

61 IPage

PERSONNEL SKILLS ASSESSMENT

A Step Above All Health Services will provide each potential employee with a skills assessment, to be completed during pre-employment process. When required, our RN Supervisor will test each prospective employee skills with a dummy, to demonstrate how candidates will provide each dictated skill while providing care for Patients in their homes. Our RN-Supervisor will assess all prospective employee using the following skills assessment tools.

SKILL ASSESSMENT

PolicJ

Skill assessment includes the skill testing of know-how that will be given to Health care professionals.

Purl!ose

The purpose of the skill testing is to assess the professional level and experience of RN,

. LPN, CAN & Home Health Aides employee.

Procedure

RN will be tested on their know how in conducting Patient's Initial assessment and Monthly visits, how to train Patients and their family members, what to do while monitoring personal care staff at the Patient's house LPN will be tested on how to take care of Patient's wound dressing and also how to correctly administer medications, Medication Technicians will be tested on how to correctly administer medications under the supervision of a registered Nurse and Nursing assistant will be tested on the types of care to provide to the Patient in their home setting and how to take vital signs for example.

62

RN SKILLS ASSESSMENT

Instructions: This checklist is meant to serve as a general guideline for our client facilities

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64

Ultrasonic Doppler I

2 3 ,i,

65 \Page

RESPIRATORY CASES

Care of a patient on peritoneal dialysis 1 2 g 4.

Care of a patient on hemodialysis Assisting with gastroscopy

1

2

g

4

1

2

g

4·

g 4•

Care of

a patient with acute hepatitis

1

2

Care of

a renal transplant patient

1

2

Care of

a patient with an acute GI bleed

1

2

g 4•

g 4

Administration of fluid, blood and blood products 1 2 g 4

Enterostomal care 1 2 g 4

1

2

g

4.

1

2

g

4

1

2

g

4•

MISCELLANEOUS

Ability to take charge duty Care of a burn patient.

Care of an AIDS patient

Administration and monitoring of IV anticoagulants I 2 g 4

Do you speak any languages other than English? □ YES □ NO If so which?

66

O = No Experience

PEDIATRIC SKILLS CHECKLIST

671 Page

1 = Perform infrequently (would require some supervision)

2 = Able to perform without any supervision

0

1

2

0

1

2

Chest physiotherapy

assist with insertion

Assessment of breath sounds

assist with removal

Pediatric head to toe assessment

maintenance of

Working knowledge of pediatric normal lab values

Working knowledge of pediatric ABG's

Suctioning (oro-naso-pharynx)

Pulse Oximeter

Child/Infant CPR

Tonsillectomy

Cleft lip/palate

Pre/post op teaching Diabetic teaching

Insertion and maintenance of IV's

IV meds mixing and administration

Care of dying infant/ child

Administration & monitoring of blood & blood products

Infusion pumps Triple lumen catheter

Hemovac

Pleuravac

NG Tube

TPN and intralipids

Feeding Tube

Details Page 1 of 1

MafY'and

BOAM RSING

Licensee Details

Demographic Information

Full Name: NYERE MURPHY Home State: Compact State

License Information

Uc#:

Status:

l�ate Renewed: f-'btained by:

R171486

Active 1/4/2016

Exam

Profession: Issue Date:

State:

Nursing

Type:

11/18/2005 Expiration Date:

REGISTERED NURSE 3/28/2018

Education Information

,chool: Profession: Specialty: r,me:

School: Profession: Specialty: fvne:

School: Profession: Specialty: fvne:

COPPIN STATE-HELENE FULD SCH

Nursing RN

Nursing RN

Nursing

BSN

BACCALAUREATE IN NURSING

BACCALAUREATE IN NURSING

RN

Employment Information

No EmQ!Qy_ment Information

License CSR Information

No License CSR Information

Check.List Information

No Checklist Information

Public Orders

I No Reiated Documents I

DISCLAIMER

The information contained in this web site is being made available as a public service by the Maryland Board of Nursing. No posted information or materials provided is intended to constitute legal or medical advice. The information contained in this web site was supplied from license applications and other sources such as schools and other states. The Maryland Board of Nursing makes no representations or warranties, either express or implied, as to the accuracy of any posted information and assumes no responsibility for any errors or omissions contained therein.

Furthennore, no warranty, express or implied, ls created by providing information through this Web Site and the presence of an individual licensee on the Web Site does not in any way constitute an endorsement by the Maryland Board of Nursing. No one shall be entitled to claim detrimental reliance on any views or information, whether provided by or accessed through this web site, or to claim any duty on our part to update posted information or to protect the interests of those accessing this web site. In r10 event shall the Maryland Board of Nursing, its contractors, or its staff be liable to you or anyone else for any decision made or action taken in reliance on such information or views. For more information regarding this Web Site or if you have any questions about information provided therein, please contact the Maryland Board of Nursing directly. The data is derived directly from the Board's Jicensure database and is usually updated on a daily basts, except weekends and State Holidays. The Boards website is considered a primary source for this data, which is the same information the Board provides though other means, such as IVR, fax, or mai! and is true and complete to the best of the Board's knowledge.

http://lookup.mbon.org/verification/Details.aspx?agency_id= I &license_id=388784&

2/3/2016

Details Page 1 of 1

MM)Aand

Bo~ RSING

Licensee Details

Demo�•aphic Informati.9n "- .. _

!Full Name: LAREISA BOYD Home State: Compact State

License Information

Lie#:

LP27334

Profession: Nursing Type:

LICENSED PRACTICAL NURSE

Status: Active Issue Date: 4/28/2000Expiration Date: 4/28/2016 Date Renewed: 2124/2014

Obtained by: Application - Active (5004) State:

!

Education Information

http://lookup.mbon.org/verification/Details.aspx?agency id=1&license_id=159214&

2/3/2016

Employment Information

No Employment Information

l:C,.Jt::�nst::_�-�-I�for!fl_atiq_n

CheckList Information

No License CSR Information I

No Checklist Information

Public Orders

I No Related Documents I

DISCLAIMER

The information contained in this web site is being made available as a public service by the Maryland Board of Nursing. No posted information or materials provided is intended to constitute legal or medical advice. The information contained ln this web site was supplied from license applications and other sources such as schools and other states. The Maryland Board of Nursing makes no representations or warranties, either

express or implied, as to the accuracy of any posted information and assumes no responsibility for any errors or omissions contained therein.

Furthermore, no warranty, express or implied, ls created by providing information through this Web Site and the presence of an individual licensee on the Web Site does not in any way constitute an endorsement by the Maryland Board of Nursing. No one shall be entitled to claim detrimental reliance on any views or information, whether provided by or accessed through this web site. or to claim any duty on our part to update posted information or to protect the interests of those accessing this web site. In no event shall the Maryland Board of Nursing, lts contractors, or its staff be liable to you or anyone else for any decision made or action taken in reliance on such information or views. For more information regarding this Web Sile or if you have any questions about information provided therein, please contact the Maryland Board of Nursing directly. The data is derived directly from the Board's licensure database and is usually updated on a daily basis, except weekends and State Holidays_ The Boards website is considered a primary source for this data, which is the same information the Board provides though other means, such as IVR, fax, or mail and Is true and complete to the best of the Board's know!edge.

Details Page 1 of 1

Maryland

Bo RSING

Licensee Details

Demo_g_raphic Information

Full Name: MARY OMOSEGHO AROJOJOYE Home State: Maryland

License Information

Lie #:

MT0039966

Profession: Medication Technician Type:

Medication Technician

!Status: Active Issue Date: 6/18/2006 Expiration Date: 8/28/2017 Date Renewed: 9/14/2015

!Obtained by: Application - Active (1) State:

Education Information

No Educatio_n Information

Employment Information

No EmQ[Qy_ment Information

License CSRInformation

No License CSR Information

CheckList Information

No Cheg_klist Information

Public Orders

No Related Documents

DISCLAIMER

The information contained in this web site is being made available as a public service by the Maryland Board of Nursing. No posted information or materials provided is intended to constitute legal or medical advice. The information contained in this web site was supplied from license applications and other sources such as schools and other states. The Maryland Board of Nursing makes no representations or warranties, either express or implied, as to the accuracy of any posted information and assumes no responsibility for any errors or omissions contained therein.

Furthermore, no warranty, express or implied, is created by providing information through this Web Site and the presence of an individual licensee on the Web Site does not in any way constitute an endorsement by the Maryland Board of Nursing. No one shall be entitled to claim detrimental reliance on any views or information, whether provided by or accessed through this web site, or to claim any duty on our part to update posted information or to protect the interests of those accessing this web site. In no event shall the Maryland Board of Nursing, its contractors, or its staff be liable to you or anyone else for any decision made or action taken in re!iance on such information or views. For more information regarding this Web Site or if you have any questions about information provided therein, please contact the Maryland Board of Nursing directly. The data is derived directly from the Board's licensure database and is usually updated on a daily basis, except weekends and State Holidays. The Boards website is considered a primary source for this data, which is the same information the Board provides though other means, such as IVR. fax, or mail and is true and complete to the best of the Board's knowledge.

http://lookup.mbon.org/verification/Details.aspx?agency_id=1&license_id=401934&

2/3/2016

Details Page 1 of 1

Maryland

Bo RSING

Licensee Details

Demographic Information

!Full Name: MARY OMOSEGHO AROJOJOYE Home State: Maryland

2/3/2016

http://lookup.mbon.org/verification/Details.aspx?agency_id=1&license_id=266327&

License In- formation -

:Lie#: A00044021 Profession: Nursing Assistant

iStatus: Active Issue Date: 10/30/2001 Date Renewed: 7/13/2015

Type: Expiration Date:

CNA 8/28/2017

l Obtained by: Waiver

State:

Education Information

No Education Information

Employment Information

No EmQ!Qy_ment lnfOririatio_n

License CSR Infor:mation

No License CSR Information

CheckList Information

i'J_o Checklist lnformatio_n

�b!ic Orders _

No Related Documents

DISCLAIMER

The information contained in this web site is being made available as a public sewice by the Maryland Board of Nursing. No posted information or materials provided is intended to constitute lega! or medical advice. The information contained in this web site was supplied from license applications and other sources such as schools and other states. The Maryland Board of Nursing makes no representations or warranties, either express or implied, as to the accuracy of any posted information and assumes no responsibility for any errors or omissions contained therein.

Furthermore, no warranty, express or implied, is created by providing information through this Web Site and the presence of an individual licensee on the Web Site does not in any way constitute an endorsement by the Maryland Board of Nursing. No one shall be entitled to claim detrimental reliance on any views or information, whether provided by or accessed through this web site, or to claim any duty on our part to update posted information or to protect the interests of those accessing this web site. In no event shall the Maryland Board of Nursing, its contractors, or its staff be Hable to you or anyone else for any decision made or action taken in reliance on such information or views. For more information regarding this Web Site or if you have any questions about information provided therein, please contact the Maryland Board of Nursing directly. The data is derived directly from the Board's licensure database and is usually updated on a daily basis, except weekends and State Holidays. The Boards website is considered a primary source for this data, which is the same information the Board provides though other means, such as !VR, fax, or mail and is true and complete to the best of the Board's knowledge.

68

PEDIATRIC SKILLS CHECKLIST

69 IP age

A STEP ABOVE ALL HEALTH SERVICES - RN SKILLS ASSESSMENT

Date of Assessment

Experience Level

!=Has Never Performed 2=Has Limited Experience

3=Comfortable Performing with Resources 4•=Proficient

PATIENT INITIAL ASSESSMENT

4,

Comprehensive Care Plan for the HHA

I

2

3

NURSE MONITORING OF AIDES

Ability to train and re-train HHA

I

2

3

Ensure HHA follows Care Plan

I

2

:J

Documentation of Patient's medication change

I

2

3

Revised care plan

I

2

3

Contact W /Patient's Doctor As needed

1

2

3

Ensure Quality Assurance

1

2

3

Coordination of Pt. Care w/ staffing coordinator

I

2

3

4,

4,

4

4

,i,

4

4,

Accurate documentation of Patient's record I 2 3 4· Name & Signature of RN being assessed Name & Signature of RN Assessing Registered Nurse. _

70

CNA SKILLS ASSESSMENT

Date

CNA Name:

RN Assessing CNA:

I.

f!.

No experience. Minimal experience

8.

4.

Moderate experience Extensive ex_per{ence

Name & Signature of CNA being assessed

Name & Signature of RN Assessing CNA

711Page

MEDICATION TECHNICIAN SKILLS ASSESSMENT

Medication Technician must be assessed and observed by the Registered Nurse Supervisor to ensure that Medication Technician has experience in administering Meds., also that MT is comfortable with the ?Rs:

Staff Monitored: Phone#: _

Nurse Monitoring Staff: _ Phone#: _

Date of Monitoring: Medication Monitoring of Aide·

This staff meets the Medication Administration Core Competencies and Qualifications as outlined above.

Registered Nurse Name and Signature Date

Staff Monitored:

72

HEALTH REQUIREMENTS FOR EMPLOYEES_AND CONTRACTORS

Policy

It is the policy of A Step Above All Health Services to only employs individuals who have their Current health clearance that includes the completion of current physical examination with physician's statement of health.

All employee/ contractor having direct contact with Patients must have documentation of baseline health screening before providing care to Patients. This includes, at a minimum, TB skin testing via the Manitou method. This testing includes the pre-placement evaluation, administration, and interpretation of TB Manitou skin tests and periodic evaluation.

l'_r_ocedure

A Step Above All Health Services procedure is to ensure adequate health status of each worker and to ensure quality of each worker to perform essential job functions. Also, to ensure that all employees and personnel are free from communicable disease before providing direct Patients care.

Repeat testing will be required if deemed necessary by the Director of Nursing for individuals with signs of communicable disease.

Each individual that A Step Above All Health Services employs must have health requirement submitted to the Agency before they can be offered employment and before they can get into contact with any of our Patients.

73IPage

For all A Step Above All Health Services employee providing direct Patients care, there will be documentation of completion of a tuberculin (TB) skin test, via the Manitou method. If there is documented evidence of a negative skin test within the twelve months prior to employment.

The TB skin test may be administered at A Step Above All Health Services by a Registered Nurse or a Licensed Practical Nurse.

The TB skin test consent and results will be documented. TB skin test results will be evaluated by a Registered Nurse or Licensed Practical Nurse, within 48-72 hours and documented as "no significant" (negative) or '"significant" (positive) in millimeters of indurations.

A TB skin test will be considered significant if:

There is a reaction of 5iuin O1 more in the following groups:

Persons who have had close recent contact with a Patient with infectious TB.

Persons who have chest x-rays with fibro tic lesions likely to represent old, healed TB.

Persons with known or suspected HIV infection.

A tuberculin reaction of 10mm or more in persons who do not meet the above criteria but who have had other risk factors for TB. This would include:

People with other medical risk factors known to substantially increase the risk of tuberculosis once infection has occurred.

Foreign-born persons from high-prevalence countries, (e.g. those from Asia, Africa, and Latin America)

74

Persons from medically under-served, low income populations, including high risk minorities; especially blacks, Hispanics. And Native Americans.

Intravenous drug users.

Residents of long term care facilities such as correctional institutions and nursing homes.

Other populations that have been identified locally as having an increased prevalence

of TB.

A tuberculin reaction of 15mm or more in all other persons. Significant results shall require; documentation in a medical evaluation, which may consist of a chest x-ray and/ or prophylactic antibiotic therapy.

Following the baseline tuberculin skin testing, repeat skin testing shall be completed at least once a year, after any possible exposure and as required by the state health department due to local outbreaks of the disease.

If the employee has had a significant reaction to a Manitou test upon employment or within the two (2) years prior to working in a position involving direct client contact, or has a significant reaction to a Manitou test in repeat testing during the course of employment, the employee and the agency must have documentation of a negative chest x-ray.

If the employee has had a significant reaction to a Manitou test more than two (2) years prior to working in a position involving direct client contact, the employee must provide documentation of a non-significant chest x-ray taken within the previous twelve (12) months or documentation that they have completed, or are currently completing a course of tuberculosis preventative therapy

75 IP age

Employees who have been exposed to active tuberculosis must document a non-significant result of a Manitou test or chest x-ray administered no earlier than ten (1 O) weeks and no later than fourteen

(14) weeks after the exposure.

Employees will require a repeat chest x-ray if signs and symptoms of active tuberculosis are present. Symptoms may include:

•Fever

•Weakness

· Weight loss

•Night sweats

· Low-grade fever

· Productive cough

•Occasional coughing of blood

,Chest pain

Hep_atitis B Vaccine:

All A Step Above All Health Services employees will be required to have Hepatitis B vaccination to protect them from the risk of exposure to blood and body fluids/ substance. All acceptance or refusal of the vaccine by the employee will be documented.

Additional Tests:

Additional test(s) may be required as directed by the State Health Department or as recommended by the health professional performing the health screening. The intent is to limit risks to the Patient, caregiver and/or other employees.

76

Documentation:

Information obtained from employees other than occupational exposure and post-exposure evaluation and follow-up during the health screening shall be documented and maintained in the employee's personnel file. This information will be confidential.

ANNUAL MEDICAL CLEARANCE: HEALTH REQUIREMENTS FOR ALL MEDICAL PERSONNEL

· Measles Mumps, Rubella (MMR) Titer unless proof of previous vaccination provided

· Hepatitis B; immunization status; counseling on Hepatitis B.

· Urine specimen for drug testing

· PPD Skin test or chest x-ray for TB, and annually thereafter

· Blood pressure screen

· Complete medical history

· Chicken Pox Titer.

771Page

PHYSICAL EXAMINATION

To insure that every clinical contractor and employer hired to provide care to A Step Above All Health Services' Client, is free from communicable disease and poses no threat to our patient, co-worker or the public.

Every employee of A Step Above All Health Services has to show documentation for TB testing and Hepatitis B in the past 12 months. If the employee has no history of contact with person with TB or has no s/s consistent with TB - Then that employee shall be considered TB free.

If the prospective employee doesn't have a doctor's documentation of a negative TB on file and doesn't have a history of a positive TB skin test, then the following procedure shall be done:

1. A Step Above All Health Services will require each individual to use his/her doctor's for a TB

skin test and if he/she is positive, then chest X-ray would be administered and the result provided to A Step Above All Health Services.

2. Every employee of A Step Above All Health Services shall be required to answer yes or no to an annual TB questionnaire.

-

3. Do you experience:

Unexplained Fevers

Yes

D

No□

Night Sweats

Yes

D

No□

Unexplained Weight Loss

Yes

D

No□

Cough

Yes

D

No□

Blood Sputum

Yes

D

No□

Hoarseness

Yes

D

No□

Signature -----------------------------------

•---Date--------

78

EMPLOYEE TB POLICY

This policy for TB Skin test and the TB Screening questionnaire shall be conducted annually. Every A Step Above All Health Services employee shall have evidence of Hepatitis B vaccine or sign a declination wavier having been told the enormous risk he/she is taking by not accepting the vaccine.

All documentation regarding health requirements shall be completed prior to starting work. The process to correct deficiency is the implementation of the enclosed health requirement policy for TB and Hepatitis B.

The time line is effective immediately. The date for this to be effective is 0 1/15/ 20I 6.

The RN Supervisor will ensure that this correction is implementation immediately. The Administrator will: Review all new hires files for inclusion

Review new employee for the completion of this employee health requirements.

Review every new hires file to assure that their requirements are not at least two weeks prior to the start of job.

The on-going quarterly monitoring of personal files regarding health requirements are to be performed every six months on all employees until the numerical strength of the employees goes up to 20, after which Agency will never balk to using a percentage of the files to review.

�-

791 Page

PATIENT'S CARE

PROVISION OF HOME HEALTH CARE SERVICES AND CRITERIA FOR DETERMINING THE NEED FOR_SKILLED SERVICES.

POLICY

A Step Above All Health Services will receive a physician's referral for services to be provided to new Patients.

Referrals are received from various authorized referral sources, to include Medicaid, DSS, Private Pay Patients and Insurance companies. The criteria for determining the need for skilled services requires a referral from the patient primary care physician.

PROCEDURE

When A Step Above All Health Services receives a referral to provide residential service for a patient, the referral will include the number of hours we are to provide Residential service for the patient; the name and address of patient including his or her telephone number.

Patients who meet the requirements of A Step Above All Health Services will be contacted by our Agency administrator to schedule a date and time that the RN-Supervisor will come in to the Patient's residence to conduct an initial assessment.

Usually, the Referral will include the diagnosis of the Patient, this will allow our Agency to determine if the type of Residential care required for and by the patient, is within the scope of services we can, and have been authorized to provide.

We will accept all Clients who need Residential Services as requested by the client, in accordance with the RSA rules and regulations and as A Step Above All Health Services

80

has been licensed for the provision of Residential Services.

Clients will be accepted depending on the availability of our staff members who can provide services as requested by the Client and our Agency's ability to provide the types of services required by the Patient in accordance with the RSA rules and regulations.

A Step Above All Health Services might be contacted by client's family members, and Clients themselves, to arrange for Residential Services. The Administrator will therefore meet with the Clients to enquire about the type of services that is needed.

If services required by the Client are not within the scope of services that we can provide, and not in accordance with the RSA rules and regulations, the Patient will be referred to the list of other licensed providers, who might be able to provide the types of services requested by the Patient.

If we are able to provide RSA services for the Patient, in accordance with the RSA rules and regulations, we will show the Client a copy of Our License to Operate as a Residential Service Agency, proof of insurance, to include a copy of our liability insurance and Bond insurance.

After all this has been done, a date will be set with the Patient, for a nurse from A Step Above All Health Services to visit the Patient at the Patient's residence, for an initial assessment.

81/Page

,--...,

A Step Above All Health Services identifies with Federal and State non-discrimination provisions. We provide Residential Service to older Adults, who are limited physically, mentally, due to age or infirmities, without regard to race, color, and creed, national origin, age, gender, religion, and handicap, marital or veteran status.

- Our primary responsibility towards all patients is to ensure that they receive Residential services by qualified, capable, caring and licensed/ certified staff of A Step Above All Health Services.

* REFERALS FROM CASE MANAGERS

When A Step Above All Health Services receives a referral from a case manager to provide Residential service for a Client. Our Agency is contacted directly by the case manager; who provides us with information on the patient.

Then, the case manager fax us a referral to include the Patient's name, patient's family member's name, telephone number and a start date.

82

SKILLED NURSING SERVICES TO PATIENTS

SKILLED NURSING SERVICES FOR COMPLEX CARE PATIENTS.

Policy

A Step Above All Health Services will provide skilled nursing services to both adult and pediatric populaces that require complex care in central region of Maryland and not limited to Baltimore county, Baltimore city, Laurel, Prince Georges, Harford, Howard, and Carol Counties.

Procedure

Complex care will be provided by RN, LPN to include wound care, tube feeding, trachea care, vent management, IV therapy and other nursing management needing the expertise of an experienced registered nurse.

A Step Above All Health Services will provide skilled nursing services to patients needing complex care in accordance with plan of care prescribed by the patient's primary care physician and under the supervision of A Step Above All Health Services Registered Nurse.

A Step Above All Health Services provides skilled nursing services to include:

a) Comprehensive health and psychological assessment.

b) Monitoring of the patient's condition.

c) Health promotion and prevention education.

d) Coordination of services

e) Teaching and training activities.

f) Provision of direct nursing care

83 IP age

Skilled Nursing Services will be provided to patients needing complex care as through an initial and ongoing assessment of the patient's physical, psychological, and environmental nursing needs; on the admission visit and subsequent visits as necessary.

The scope and intensity of ongoing assessment will be determined by the patient's diagnosis, condition, need and desire for care, response to previous care. The RN supervisor will initiate and revise the patient's plan of care in collaboration with the patient's physician as necessary.

Initiation of appropriate preventive and rehabilitative nursing procedures:

· Preparation of clinical record and progress notes.

· Consultation with and education of the patient and family regarding disease process, self-care techniques, and prevention strategies.

· Coordination of services.

· Referral to other health care professionals as needed.

· Communication with patient's physician and other home health employees regarding changes in patient's condition.

· Informing the physician and other employees of change in patient's needs.

· Evaluating the effectiveness and outcome of care.

· Planning for the patient's discharge from service.

· Documentation of care provided.

· RN supervises the clinical duties of an LPN. Hence, LPN shall not admit patients.

84

Licensed practice Nurse Limitations in the provision of care for patients needing complex care:

· LPN shall not admit patients;

· LPN shall not provide intravenous therapy services;

· LPN shall be supervised by RN no less frequently than every six visits or two weeks, whichever comes first.

85 IP age

POLICY ON WOUND MANAGEMENT

DATE OF APPROVAL BY GOVERNING BODY -02/10/20_lf3_

PQlicy

It is the policy of A Step Above All Health Services that should it be determined that a Patient is in need of wound management care. A Step Above All Health Services will have skilled personnel assigned to meet the Patient's needs.

PROCEDURE

A Step Above All Health Services will focus on a regimen to eliminate any pressure ulcers or wounds, to provide all appropriate care, to monitor to assess the progress in healing and be ready to make accurate and detail report to determine that the Patient is receiving the necessary care for recovery.

A Step Above All Health Services will be diligent to evaluate whether or not the treatment being given by the personnel assigned is meeting the needs of the condition, and if treatment needed is beyond the capabilities of the personnel of our agency that other appropriate caution be taken immediately to ensure the health and safety of the Patient.

A Step Above All Health Services will ensure that if the Patient is in need for more aggressive treatment is facilitated as quickly as possible.

A Step Above All Health Services wound management will consist of the following:

· DON assessment and review of the healthcare practitioner plan of treatment

* Assessment of the best qualified staff to fully carry out all doctors' orders

· Perform a physical examination that includes a thorough inspection of the client

/~ skin

86

· Evaluate the extent of the pressure ulcer and any other possible medical problems that may have contributed to the development of the pressure ulcer, so as to assure that the personnel properly address the situation.

· The assigned personnel will follow through with all non-surgical treatments that may include:

� Cleansing ulcer.

� Removing the infected and dead tissue from the ulcer {debride-ment)

� Using a dressing on the ulcer

� Monitoring the ulcer regularly to see if it is healing

* The assigned personnel will examine the ulcer every time the dressing is changes to determine if the treatment plan is working and that the ulcer is healing. Imme-

diately report any additional problems to the Health Care Practitioner to include:

� Any pain or discomfort around the wound or ulcer reported by the client

� Any change in swelling, skin color, or skin temperature

� Fluids seeping through the dressing

� A strong smell around the dressing

A Step Above All Health Services will at a minimum follow observe and following steps:

® Wash hands. (minimum 60 seconds)

® Put on Gloves

® Remove wound dressing

® Dispose of all dressing as the Agency waste disposal policy

871 Page

@) Assess the wound or pressure ulcer for the following:

:l€ Color and drainage of the wound

:l€ Measure the diameter of the ulcer with a measuring device

:l€ Measure depth of ulcer using sterile, cotton-tipped application

:l€ Measure depth of undermining skin by lateral tissue necrosis,

:l€ Assess for any odor

Wound must be classify in one of the following stages and category:

STAGE I - Reddened area or region of pallor and mottling, following by erythema. Reddened area disappears when pressure is relieved. In a wound ulcer, erythema blanches. Blanching does not usually occur in a later stage.

STAGE II-

STAGE III-

STAGE IV-

(partial-thickness wounds) Subcutaneous epithelial damage has occurred. Area is reddened and edematous; may have excoriation or blister redness does not disappear when pressure is relieved. Surrounding area is red and scaly with irregular borders.

(shallow, full-thickness wounds) - subcutaneous tissue layer destruction; necrotic tissue; destruction of capillary bed, producing serosanguinous drainage. Surface of ulcer will likely be smaller that internal diameters.

(deep, full-thickness wounds) - Destruction of deep tissue, extending through subcutaneous layers into muscle mass and bone. Ulcer edge appears to "roll over" into the defect and is a tough, fibrinous ring.

88

ESCHAR- A tough, membranous layer covering ulcer. Lauer may be rigidly adherent to the base of the wound. This stage is difficult to determine unit; eschar has sloughed off or has been removed surgically.

Redress wound following appropriate wound care dressing procedures.

A. Document in the clinical record the following data:

· Wound/ulcer assessment, including color, drainage, odor, and size

· Wound/ulcer classification

· Wound care and dressing change procedure

· Client systems and response to the procedure

891 Page

WOUND CARE

Procedure

Taking proper care of your wound will help it heal. Our team of healthcare professional at A Step Above All Health Services will provide excellent care for your wound and dress your wound to help heal faster. Our Nurse will also explain how to tell if the wound is healing normally.

Here are the basic steps that you should expect while our nurse is caring: for your woun<!.;,

· Our nurse will wash his/her Hands before providing care for your wound;

· Will wear gloves before providing care for your wound;

· Will throw away used dressings and disposable supplies immediately after use, this will Help avoid infecting the wound or spreading germs.

PROCEDURE

· Our Nurse at A Step Above All Health Services will use liquid soap and lather for 2 minutes. Will scrub between his/her fingers and under his/her nails.

· Will rinse with warm water, keeping his/her fingers pointing down.

· Will use a paper towel to dry his/her hands and to turn off the faucet.

Ihen he/she will begin to care for your wound by Removing the Used Dressing

· He/She will set up his/her supplies.

· Will put on disposable latex gloves.

· He/she will gently take off the old dressing. If you have a drain or tube in the wound, A Step Above All·Health Services nurse will be careful not to pull on it.

· He/She will loosen the tape by pulling gently toward the wound.

90

· Will remove the dressing one layer at a time and put it in a plastic bag and tie it before placing it in the trash can.

· Will remove gloves and wash hands again.

Inspecting and Dressing Your WQund

Each time our nurse changes your dressing, he/she will inspect the wound carefully to be sure it's healing normally.

You should call Our Nurse at A Step Above All Health Services if you see any of the following signs of a problem:

· Bleeding that soaks the dressing

· Pink fluid weeping from the wound

· Increased drainage or drainage that is yellow, yellow-green, or foul-smelling

· Increased swelling or pain, or redness or swelling in the skin around the wound

· A change in the color of the wound

· An increase in the size of the wound

· A fever over 10 J.0°F, increased fatigue, or a loss of appetite.

Recognizing and Treating Wo11n<ilnfe_ction

Wounds can become infected with harmful bacteria. This prevents healing and increases the risk of scars. In some cases, the infection may spread to other parts of the body. And infection with the bacteria that causes tetanus can be fatal. Know what to watch for and get prompt treatment for infection.

Risk Factors

A wound is more likely to become infected if it:

· Results from a puncture, such as from a nail or piece of glass.

91 IPage

· Results from a human or animal bite.

· Isn't cleaned or treated within 8 hours.

· Occurs in your hand, foot, leg, armpit, or groin.

· Contains dirt or saliva.

· Heals very slowly.

· Occurs in a person with diabetes, alcoholism, or a compromised immune system.

Symptoms of Infection

Call your healthcare provider at the first sign of infection, such as:

· Yellow, yellow-green, or foul-smelling drainage from a wound

· Increased pain, swelling, or redness in or near a wound

· A change in the color or size of a wound

· Red streaks in the skin around the wound

· Fever

Treatment for infection

Treatment is likely to depend on the type and extent of your infection. Our team of healthcare professional at A Step Above All Health Services may contact your doctor, to obtain prescribe oral antibiotics to help fight bacteria.

He or she may also flush the wound with an antibiotic solution or apply an antibiotic ointment. Sometimes an abscess (a pocket of pus) may form. In that case, the abscess will be opened and the fluid drained. You may need hospital care if the infection is very severe.

.-.

92

WOUND CARE, PEDIATRIC

Policy

It is the policy of A Step Above All Health Services that Wound care is performed by a nurse who has experience in techniques of wound management and dressing change for children.

Procedure

Topical wound care is provided to children to support a healing environment and minimize the risk of complications. The procedure requires familiarity with dressing materials, wound-cleaning solutions, and wound-cleaning techniques, and topical medications, methods to secure the dressing, and support surfaces, such as specialty beds, mattress overlays, and seating surfaces.

In addition to direct wound care, the child will receive adequate systemic care to promote wound healing and also to minimize the risk of complications. This process includes maintaining proper nutrition, fluid balance, gas exchange, circulation and administering systemic medications.

A Step Above All Health Services Nurses provide Interventions to reduce or eliminate causative factors in wound formation, such as moisture, pressure, shear, and friction.

Additional interventions will also be provided by A Step Above All Health Services Nurses; to minimize the deleterious effects of immobility, neuropathy, paralysis, impaired circulation, and impaired oxygenation.

93 Ip age

If the wound is a result of pressure, pressure will be kept off the area, even if a support surface is used, and the child's skin and bony prominences are assessed at least daily for pressure ulcers.

Care and management techniques may vary based on the type of wound and the setting of the child. A Step Above All Health Services will utilize clean technique; which involves using nonsterile dressings and nonsterile disposable gloves or freshly washed clean hands; since the care will be provided in the home setting.

Pharmacologic and non-pharmacologic measures will be used before and during wound care procedures to minimize child's discomfort during the procedure.

A Step Above All Health Services professionals will ensure that a doctor orders wound care with specific written directions for the type of cleaning solution, topical antimicrobial or antiseptic agent, and dressing material. Any wound that appears suspicious for infection should be cultured.

94

---

E!l!!!l!ment

· Nonsterile gloves

· Sterile gloves (for sterile dressing changes)

· 2" x 2" or 4/' x 4" gauze pads

· Sterile normal saline solution or tap water

· Wound-cleaning solution

· Cotton-tipped applicators

· Dressing materials

· Tape or other method to secure dressing (such as Montgomery straps)

· Biohazard bag

· Optional: topical antimicrobial or antiseptic, mineral oil or petrolatum

lm_p_lementation

A Step Above All Health Services nurse will:

· Review the doctor's order for wound care and determine the type of cleaning solution, topical antimicrobial or antiseptic agent, and dressing material to use.

· Review the child's medical record for pertinent history, focusing on the primary reason the child has a wound (for example, surgical incision, intravascular access site, pressure ulcer, accidental injury) and notes about previous dressing changes.

· Wash your hands.

· Gather the necessary supplies.

· Inform the child and his parents of the frequency and type of wound care that will be provided. Describe the procedure and if appropriate, demonstrate the procedure on a doll.

· Assess the child and family's ability and desire to participate in the wound care and dressing change process.

· Assess the child's developmental level and readiness to learn.

· Determine whether the dressing change should be performed in the treatment room to ensure the child's room remains a "safe location"free from pairifu.l experiences.

· Assess the child's pain level. Provide appropriate pain relief interventions before initiating wound care if needed.

· Place the child in a position of comfort so that the wound site can be easily reached during wound care. Protect the child's privacy by keeping other body parts well covered.

· Wash your hands and put on nonsterile gloves.

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TRACHEOSTOMY SUCTIONING POLICY

Polici

It is the policy of A Step Above All Health Services to ensure that skilled nursing service for tracheostomy procedure is performed in a manner that will safeguard the health, safety, and medical well-being of the Patient. The highest standards and procedures will be followed to maintain a patient's airway at all times. We will perform all services with sterile techniques.

PROCEDURE

A Step Above All Health Services will be certain that all staff and personnel that will be assigned to duties in the performance of service of tracheostomy management will be skilled in the duties required for the health and safety of the patient. The DON will assess the demonstration of skills for all licensed and certified staff assigned to Trak Patient.

At a minimum A Step Above All Health Services employees will utilize the following procedures:

Wash hands (for a minimum of 60 seconds)

Client will be placed in the high-fowler's position, if appropriate. Cocer the patient's chest with a towel.

Prepare suction equipment. Turn the machine on. Set the vacuum regulator to appropriate negative pressure, if the machine is variable. (Elevated pressure settings increase the risk of trauma to the tracheal mucosa.

Open catheter and supplies. Put on Gloves. Pour water or normal saline in basin.

Sterile technique: Use sterile technique with sterile gloves and supplies as indicated above.

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Clean Technique: Use clean technique with clean gloves and supplies as noted above.

Attach the catheter to tubing.

· Suction a small amount of water from the basin.

· Lubricate the catheter tip with water-soluble lubricants.

· With you thumb off the control, insert the catheter approximately five inches into the tracheostomy. This minimizes the risk of mucosal damage and hypoxia and positions the catheter correctly.

· Apply intermittent suction by placing and removing the thumb over the control as you gently withdraw the catheter while rotating it back and forth between the thumb and index finger. Encourage the client to cough.

· If secretions are difficult to remove, you may instill 3-5 ml of sterile normal saline into the Tracheostomy.

· Place the catheter into water or normal saline. Apply suction to rinse the catheter and connecting tubing.

· Allow for a rest period (one time three minutes between passes) and repeat procedure until the airway is cleared. Limit suction time to three to five minutes. Reapply oxygen as needed.

· Perform nasal and oral pharyngeal suctioning after tracheal suctioning 1s completed. This removes upper airway secretions and prevents additional introduction of microorganisms into the respiratory tract.

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· Remove gloves and dispose of equipment according to the agency waste disposal policy.

· Reassess the client's respiratory status

For clean techniques procedure, catheters may be reused.

· Clean in warm, soapy water.

· Rinse with water and dry thoroughly.

· Store in a clean, dry area.

Documentation in Patient's record will be the following:

· The client's tolerance of suctioning procedure

· Secretions obtained: Odor, color, amount, consistency

· Frequency of suctioning

· Catheter size

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SUCTIONING A TRACHEOSTOMY

Suctioning keeps your trach tube clear of excess mucus. Suction as instructed by your health care provider. Follow these guidelines and any others you're given.

J. Collect Your Supplies

Find a clean, well-lighted space near a sink and mirror. Collect your supplies: a suction machine, a clean suction catheter, and a small bowI of distilled water. Wash your hands with soap and warm water. Then, put on clean, disposable, powderless gloves.

fl. Prepare to Suction

· Turn on the suction machine to mm Hg.

· Attach the suction catheter to the suction machine.

· Dip the catheter tip into the distilled water to assure the suction is working.

· Do the following only if your health care provider tells you to: Put a small amount of sterile saline

· solution into your trach tube. This will help loosen mucus.

3. Insert the Catheter

· Take a few deep breaths to fill your lungs with oxygen.

· Gently insert the catheter into your trach tube.

· While you insert the catheter, do not suction.

· Stop inserting the catheter when you start to cough.

4. Suction

· Apply suction. At the same time, slowly pull the catheter out of your trach tube.

· Move the catheter tip in a circle as you pull the catheter out.

· The catheter should be out of your trach tube within 5-10 seconds.

· If you need to suction more, relax and breathe for a few minutes before you start

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agam.

· When you have finished suctioning, turn off the suction machine.

· Discard the used catheter, water, and gloves.

Cleaning Your Tracheostomy

Clean your trach tube and the skin around it at least once a day. Cleaning helps prevent infection and skin irritation. Follow these steps and any other guidelines you are given.

1. Collect Your Supplies

· Choose a clean, well-lighted space near a sink and mirror. Collect your supplies: lint-free bandages, cotton swabs, a trach tube brush, and a bowl filled with dis-tilled water and hydrogen peroxide in equal parts.

· Wash your hands with soap and warm water. Put on clean, disposable, powder-less gloves.

f!. Remove the Inner Cannula

· Hold the neck plate with one hand. With the other hand, unlock the inner can-nula (tube). Gently remove the inner cannula.

· Do not remove the outer cannula.

3. Clean the Inner Cannula

· Soak the inner cannula in the bowl of distilled water and hydrogen peroxide.

· If the inner cannula is reusable, clean it with a trach tube brush. Do not use a toothbrush. Rinse with distilled water.

· Put the wet inner cannula back into the outer cannula. Lock the inner cannula in place.

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4. Clean Your Neck Plate and Skin

· Remove the soiled gauze, if used, from behind the neck plate. Clean the neck plate and the skin under it. Use a clean gauze pad or a cotton swab dabbed in distilled water. Gently pat the skin dry.

· If instructed by your doctor, put a clean, precut gauze pad under the neck plate.

This pad protects your skin.

· Tracheostomy Tube or Stoma: Your New Airway

If your surgeon has given you a new airway during surgery, it may be in place only a short time while you heal. Or, if your larynx has been removed, you'll continue breathing through this new airway. In either case, your healthcare team will help you adjust.

· If You Have a Tracheostomy Tube

Your tracheostomy (trach) tube has been chosen to fit well and work right for you. You'll learn how to keep it clean and clear. Often, a trach tube is needed only a short time. Your surgeon will tell you how long to use the tube. If you don't need a new airway after surgery, the hole in the front of your throat will likely close on its own. In some cases, surgery is needed to close the hole.

· If You Have a Stoma

If your larynx was removed during surgery, you'll continue to breathe through the hole in your throat. This hole is called a stoma or permanent tracheostomy. You'll be shown how to care for your stoma. Support groups can help you adjust to having a new airway. And you can return to work, family lite, and many of the activities you enjoyed before surgery.

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CHANGING A TRACHEOSTOMY TUBE

DATE OF APPROVAL BY GOVERNING BODY-02/10/2016

PURPOSE

· To change the client's tracheostomy tube.

· To prevent respiratory infection.

· To maintain adequate ventilation.

· To prevent any tracheal damage.

APPLIES TO:

· Registered Nurses

· Licensed Practical/Vocational Nurses

EQUIPMENT /SUPPLIES

· Tracheostomy care and suctioning supplies (see Tracheostomy Care procedures)

· Tracheostomy tube*

· 5 to 10 ml syringe

· Sterile water-soluble lubricant

· Stethoscope

· Disposable gloves

*Note: Use sterile tube as ordered by the physician

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� PROCEDURE

1. Wash hands. Refer to the Hand Washing procedure

2. Don cleaning gloves

3. Suction the client per Tracheostomy Suction procedure

4. Prepare new tracheostomy tube

a. Remove Inner cannula from outer cannula and put obturator in place.

b. Attach syringe to the end of the cuff (for cuffed tube).

c. Inflate cuff slowly to verify patency (for cuffed tube).

d. Withdraw air (for cuffed tube).

e. Lubricate end of tube.

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f. Place new ties on one end of tube.

g. Set aside.

5. Cut existing tracheostomy ties: hold tube in place with non-dominant hand.

6. Pick up new tube in dominant hand.

7. Gently remove existing tracheostomy tube and insert lubricated outer cannula with obturator into stoma. Insert downward and inward.

8. Following insertion, remove obturator, insert inner cannula and "lock" it into place. If the client is on a ventilator, reconnect within 30 seconds.

9. Secure the tube in place with clean ties and dressing per Tracheostoiny Care proce-dure.

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10. If the tube is culled, inflate after insertion with 5 to 1O ml of air. Inflate during inspiration, if possible.

I !.Place stethoscope at the side of the neck just below the chin near the tracheostomy tube while injecting air into the cuff Listen until you can no longer hear air going past the stethoscope. When the sir sound stops, a seal has been formed and minimal occluding volume attained.

12. Check cuff seal for leakage by feeling for air escaping from the nose, mouth or tracheostomy site.

13. Dispose of disposable supplies and clean reusable equipment according to the Agency Waste Disposal Policy. If tracheostomy tubes are to be reused, clean them in hydrogen peroxide and distilled water or saline, boil for 10 minutes, rinse and dry thoroughly.

14. Remove gloves and wash hands. Refer to the Hand Washing procedure.

15. Wrap or cover clean supplies in a clean towel.

DOCUMENTATION GUIDELINES

1. Document in the clinical record:

a. Cuff pressures noted and tracheal breath sounds.

b. Suctioning performed and appearance of secretions

c. Tolerance of procedure

d. Client/caregiver instructions and compliance with procedure

i. Date and time tracheostomy tube was changed.

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11. Appearance of stoma site and drainage, if present.

111. The client's tolerance of procedure 1v. Respiratory.

PRINCIPALS OF CUFF MAINTENANCE

· Check tracheal breath sounds every 4 - 8 hours and note pressure of pilot balloon between fingers.

· Per agency policy, check cuff pressure and note if minimum occlusive volume in-creases or decreases (usually done every 8 hours).

· If tube feedings or oral feedings are being given, assess secretions for tube feeding or food particles.

RELATED PROCEDURES

Tracheostomy Care, Tracheostomy Suctioning

Questions and Answers

Q: Will I be able to speak with a tracheostomy?

A: Yes. Most tracheostomies can be fitted with a speaking tube.

Q: Will I be able to eat nornially with a tracheostomy?

A: Yes. Most patients can eat normally, but some precautions are needed.

Q: How long will it take for my opening to heal once the tracheostomy tube is removed?

A: In most cases, healing only takes a few days.

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PROCEDURE

A tracheostomy (tray-kee-AHS-toe-mee) gives you a new pathway for air to go into and out of your lungs. To create this pathway, you need surgery to make a small opening in your neck. A tracheostomy tube (also called a "trach tube") is then placed into this opening. Air flows into and out of your lungs through the tube.

I. Wash hands and dry. Refer to Hand Washing Procedure. Don clean gloves.

2. Perform tracheal suctioning per tracheal suctioning procedure. This removes se-cretions and decreases the clients need to cough during the procedure.

3. Removed soiled tracheostomy dressing prior to removing gloves. Discard dressing inside the glove with suctioning catheter.

4. Assemble supplies using aseptic technique:

a. If a Tracheostomy Care 1-1:it is used, open the kit and spread the package on the table.

b. Open the cotton-tipped swabs. Pour hydrogen peroxide on one and normal saline solution on the other.

c. Obtain a clean basin and fill it with approximately ¾ inch of hydrogen per-oxide.

d. Place brush in basin.

e. Prepare tracheostomy ties. Use scissors to cut to proper length.

f. Do not recap the normal saline solution or the hydrogen peroxide as they will be needed later in the procedure.

5. Wear gloves.

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Note: for tracheostomy tubes with an inner cannula, follow procedures numbers 6 through 16. For tracheostomy tubes with no inner cannula, follow procedure numbers 12 through 16.

6. If the client is receiving oxygen therapy, remove the oxygen source.

7. Remove the inner cannula and place into basin. (Hydrogen peroxide loosens secre-tions in the inner cannula.)

8. If the client is on oxygen or mechanical ventilation, replace oxygen source on or over the tracheostomy site. This provides a supply of oxygen to the client and pre-vents oxygen desaturation.

9. Hold and clean the inner cannula using the small brush on the inside and outside of the cannula.

I 0. Pick up the inner cannula and hold over the basin. Rinse thoroughly with normal saline (pour over and through cannula) and shake off excess fluid.

11. Replace inner cannula and secure into place. Replace oxygen source.

12. Clean exposed stoma site and outer cannula areas with hydrogen peroxide pre-pared, cotton-tipped swabs first. Follow by using 4_.'' X 4·" gauze pads. Clean in a circular motion from the stoma site outward. Be sure to clean under the tracheost-omy tube faceplate.

13. Rinse the hydrogen peroxide from the tube and site using normal saline prepared cotton-tipped swabs and 4" X 4" following the same technique as in step 12.

14. Prepare and apply new tracheostomy ties. Do not remove the old ties until the new ties are secured.

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a. Measure ties so they are long enough to go around the patient's neck twice. Cut the ends diagonally.

b. If an assistant is present, have him or her hold the tracheostomy by the neck plate by while clipping and removing the old ties. Slip the ends of the new ties through the holder and the neck plate and secure ties. Slide both ends around the client's head and neck. Insert one tie through the second eyelet opening and pull snugly.

c. Tie the ends securely with a double square knot, allowing one finger space in the tie. The tracheostomy should be secured without binding. The knot should be located on the side of the client's neck.

15. Place a split 4" X ,1" dressing under the tracheostomy faceplate and ties.

16. Assess respiratory status and the client's tolerance of the procedure.

17. Recap the hydrogen peroxide and normal saline bottles. Label the bottles with the dates they were opened.

18. Clean reusable supplies in warm, soapy water. Rinse thoroughly and dry between two paper towels. Store supplies in a loosely closed, clear plastic bag.

19. Remove gloves and discard disposable supplies according to the Agency Waste Dis-posal Policy.

20. Wash hands. Refer to the Hand Washing procedure.

R�asons for a TracheostomJ:

Some of the reasons that a tracheostomy may be needed include:

· Swelling of the throat that blocks the airway (such as from an allergic reac-tion)

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· Damage to the throat (such as a burn)

· An object or growth that blocks the throat or trachea

· Respiratory failure and the need for extra oxygen, such as with severe emphy-sema

· Problems breathing during sleep (sleep apnea)

· Paralysis of the abdomen, chest, neck, or throat that affects breathing

· Surgery on the larynx

· Cancer in or near the trachea

· Need for long-term ventilation

· How a Tracheostom)'_ Works

· Surgery is done to make a small opening through the front of your neck into your trachea. This opening is called a stoma. A short tube (trach tube) is placed into the stoma. One end of the trach tube rests outside of your neck.

· The other end rests inside your trachea. When you breathe in, air flows through the trach tube into your trachea and to the lungs. When you breathe out, air flows back out of the trach tube. Some people need the new airway for only a short time. Others may need it for good. Your doctor or surgeon will discuss your needs with you.

EQUIPMENT SUPPLIES

· Tracheostomy suction supplies*

· Bedside table or workplace

· Towel

· Hydrogen peroxide

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· Normal saline

· Three 4"X 4:' gauze pads (or more if stoma has much drainage)*

· Four cotton-tipped swabs*

· Split 4" X 4" pad (pre-cut tracheostomy dressing)*

· Basin*

· Small brush*

· Tracheostomy ties

· Scissors

· Two pairs of disposable gloves*

*Note: Tracheostomy care is to be done with sterile technique, these items must be sterile.

DOCUMENTATION GUIDELINES

I. Document in the clinical record:

a. Character of respirations

b. Status of the tracheostomy site

c. Color, consistency and amount of secretions

d. Date, time and care provided and supplies used

e. The client's tolerance of the procedure

f Replacement of oxygen required

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PEDIATRIC CONSIDERATIONS

· Since the air that the child breathes no longer passes through the nose and mouth, it is not warmed, moistened and filtered before it enters the lungs. To keep mucous liquid so that it is easy to remove, added moisture is needed. Increase fluid intake as well as humidifying the air the child breathes.

· Tracheostomy in children makes it harder for the child to communicate needs. Monitors and other non-verbal modes of communication can be used.

· Trach secretions can irritate the skin around the tracheostomy and may cause in-fection. Wash skin with soap and water and deep dry. Change trach ties as often as indicated.

· Adult supervision is needed when the child is near water.

· Any smoke, aerosol sprays, powder or dust can irritate the lining of the child's trachea. Child should not share a room with anyone who is smoking.

· All people who care for the child with a trach must know how to suction and anyone caring for the child alone should know CPR.

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DISCHARGE INSTRUCTIONS: CARING FOR TRACHEOSTOMY TUBE AND STOMA

You have had surgery to create an opening through your neck and into your trachea. A tube (cannula) was inserted into the opening to allow you to breathe.

You need to take care of your tracheostomy ("trach") tube, your stoma (the opening in your neck), and the skin around the stoma. Your healthcare team will teach you how to do this. The guidelines below will also help.

· Cleaning Your Trach Tube and Stoma

Clean your tube and the skin around it at least once a day. Follow these steps and any other guidelines you have been given. Choose a clean, well-lighted space near a sink and

mUTOr.

Step 1

Collect the following supplies:

· Lint-free bandages

· Cotton swabs

· Trach tube brush

· Bowl filled with equal parts of distilled water and hydrogen peroxide

· Wash your hands with soap and warm water. Put on clean, disposable, powderless gloves.

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Step 2

Remove the inner cannula (tube).

· Hold the neck plate with one hand. With the other hand, unlock the inner cannula. Gently remove the inner cannula.

· Don't remove the outer cannula (tube).

Steps

Clean the inner cannula.

· Soak the inner cannula in the bowl of distilled water and hydrogen peroxide.

· Clean the inner cannula with a trach tube brush. Don't use a toothbrush. Rinse with distilled water.

· Put the wet inner cannula back into the outer cannula. Lock the inner cannula in place.

Step 4

Clean your neck plate and skin.

· Remove the soiled gauze, if used, from behind the neck plate. Clean the neck plate and the skin under it. Use a clean gauze pad or a cotton swab dabbed in distilled water. Gently pat the skin dry.

· Put a clean, precut gauze pad under the neck plate. This pad protects your skin.

If Your Trach Tube Becomes Plugged

It is normal to have some mucus in your airway, but mucus can build up and thicken. If this happens, your trach tube can become plugged. Follow these steps and any other guidelines you have been given to clear your trach tube.

Find a clean, well-lighted space near a sink and mirror.

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Collect the following supplies:

· Suction machine

· Clean suction catheter (tube)

· Small bowl of distilled water

Wash your hands with soap and warm water. Then put on clean, disposable, powderless gloves.

Prepare to suction:

· Turn on the suction machine to mm Hg. (Use the setting you were given by your healthcare provider.)

· Attach the suction catheter to the suction machine. Ensure the suction is working: dip the catheter tip into the distilled water.

Insert the catheter into your trach tube:

· Take a few deep breaths to fill your lungs with oxygen.

· Gently insert the catheter into your trach tube. While you are inserting the catheter, don't suction. Stop inserting the catheter when you start to cough.

Suction:

· Apply suction. At the same time, slowly pull the catheter out of your trach tube. Move the catheter tip in a circle as you pull the catheter out.

· Take 5 to 10 seconds to remove the catheter completely from your trach tube. If you need to suction more, relax and breathe for a few minutes before you start again.

When you are finished, turn off the suction machine. Discard the used catheter, water, and gloves.

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Follow-Up Doctor's Appointment

Make a follow-up appointment as directed by our staff.

When to Call Your Doctor

Call your doctor right away if you have any of the following:

· Shortness of breath, wheezing, or coughing

· Red, painful, or bleeding stoma

· Swelling around the trach tube

· Fever of 100.4°F or higher, or chills

· Yellow, smelly, bloody, or thick mucus

· Vomiting that doesn't go away

Note: If you ever have trouble breathing, call 911 (emergency) right away.

Tracheostom,)': Care

You need to take care of your trach tube, your stoma, and the skin around the stoma. You will be told by your health care team how to do this. The guidelines below may also help you.

Keeping the Tracheostomy Clean

· To take care of your skin and prevent infection, you need to keep your tracheost-omy clean.

· You will be shown how to do this.

Clean the tracheostomy at least once

· a day.

· Clean more often, if you need to.

Keeping Your Trach Ties Clean

· Trach ties fit around your neck to hold your tube in place. They will get dirty.

· Plastic ties can be wiped clean.

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· Fabric ties need to be changed when they are dirty.

· You will be shown the best way to change your ties.

Keeping the Trach Tube Clear

There is always some mucus in your airway. But mucus can build up and thicken. If this happens, your trach tube can become plugged. To keep the trach tube clear of mucus buildup, you may need to do one or more of the following:

Suction the mucl!§ out of the airwa:I', To do this, you use a special machine. You will be told how to suction and how often.

Mgisten the air you breathe. Normally, the nose moistens air as it is breathed in. With a tracheostomy, you need another way to moisten the air. Ask your health care provider what method of moistening the air you should use.

Call your doctor right away if you have any of these problems:

· Red, painful, or bleeding stoma

· Swelling around the trach tube

· Fever over 10 J.0°F

· Yellow, smelly, bloody, or thick mucus

· Vomiting that doesn't go away.

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MECHANICAL VENTILATION MANAGEMENT POLICY

Policy

A Step Above All Health Services RN Supervisor provides a guideline to qualified nursing stafl:; on the proper care of the patient whose medical management includes the use of any of the devices of mechanical ventilator support.

Procedure

A Step Above All Health Services provides Mechanical ventilator support to patients through a wide variety of mechanical, pneumatic, electronic, and microprocessor-driven devices for the purposes of life support during acute respiratory failure, therapeutic support of suboptimal cardiopulmonary function, or therapeutic support of chronic ventilator failure.

A Step Above All Health Services mechanical ventilator support is provided as follows:

· Maintain alveolar ventilation to ensure adequate elimination of carbon dioxide.

· Maintain arterial oxygenation to ensure adequate delivery of oxygen to the tissues.

· Minimize the risk of adverse pressure and volume effects on the lungs (e.g., baro-

/volu trauma) and cardiovascular system.

· Aim for patient comfort.

· Provide appropriate reconditioning workloads as well as muscle rest during recovery.

Specific instruction for the use of any of the devices of ventilator support will be obtained from the Operator's Manuals for the devices.

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lmp_lementation

'I/¼ Check the doctor's order. If the patient isn't already intubated, prepare him for intubation.

'I/¼ Gather and prepare the necessary equipment.

* When possible, explain the procedure to the patient.

· Make sure the patient is being adequately oxygenated.

· Wash your hands, and put on gloves and personal protective equipment.

· As the patient's condition allows, perform a complete physical assessment, and draw

blood for ABG analysis to establish a baseline.