Colorado Asissted Living policy and procedures manaual edit .
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assisted_living_policy_and_procedure_manual.doc
Assisted Living Policy and Procedure Manual
Notice
When using this manual, please consider the following important points:
1. The policies and procedures outlined in the manual will never supersede current regulation. To the best of our knowledge, these guidelines reflect current regulation; nevertheless, they cannot be considered universal recommendations. For individual application, all recommendations must be considered in light of the resident’s condition. The authors and publishers disclaim responsibility for any adverse effects resulting directly or indirectly from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text or video content.
2. Regulations and interpretations will change and it is your responsibility to ensure that the assisted living or residential care community is operated under the guidelines outlined in current regulation. Review regulations, policy, procedures and instructions to ensure compatibility with the regulations your community is obligated to abide by.
3. The guidelines outlined in this manual will never supersede a state regulatory agency’s directive, physician order, or direction from a licensed medical professional.
4. Hands-on resident care of any kind should always be in accordance with physician orders. The interventions in this manual are not intended to be personalized plans of care.
Copyright ( 2009 by Care and Compliance Group, Inc.
All rights reserved. Permission is granted to photocopy written materials, certificates and quizzes for internal use within the purchasing organization. Otherwise this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the publisher.
Table of Contents
9 Personal Property/Theft and Loss
12 Abuse, Fraud, and Wrongdoing
18 Resident Independent Departure Assessment
20 Firearms
23 Dignity
24 Corporal Punishment and Restraints
25 Complaints
26 Staffing
30 Job Description: Administrator
31 Job Description: Assistant Administrator
33 Job Description: Resident Care Coordinator
35 Job Description: Medication Aide
39 Volunteers
42 Resident Pre-Admission Appraisal
44 Allowable Health Conditions
50 Ongoing Resident Appraisals
59 Move-Out
64 Use of Assistive Devices and Ambulatory Aids
67 Dressing
70 Incontinence
84 Resident Arrives with a Medication
86 Medications are Permanently Discontinued
87 Hold Orders
89 Medications Left Behind by a Resident
90 Medication Refusal and/or Missed Doses
92 Transferring Medications for Home Visits and Outings
94 Use of Emergency Medications
95 Injections
97 Over-the-Counter (OTC) Medications
99 Warfarin and Other Anticoagulants
100 Narcotics, Controlled Substances, and Preventing Drug Diversion
102 Emergencies and Medical Needs
103 Physician and Other Medical Appointments
104 Labs and Outside Medical Services
105 Licensure of Nursing Personnel
109 Falls
112 Elopement/Missing Resident
118 Confidentiality
119 Narrative Charting Entries
120 Incident Reports
120 Procedure
121 Abbreviations
Terminology
Various terms related to resident care are used throughout this manual. While most of these terms are commonly accepted in the industry, there is some variation from state to state, and within different organizations. To clarify these terms and to improve your understanding of how they are used in this manual, a brief explanation is provided below:
Administrator This is the person responsible for the day-to-day operations of the assisted living or residential care community. Some state regulations specify other terms for this individual, such as manager, and many organizations will refer to this person as the "executive director."
Assisted Living The specific terms used to describe assisted living vary from state to state, but in this manual we refer to assisted living as a homelike care setting that providers direct care and supervision 24 hours a day, 7 days a week, in addition to room, board, and other services. Other common terms include residential care.
Community The care setting is referred to as an assisted living or residential care community. Although the term "facility" is often used in state regulations and by some in the industry, we feel it is important to distinguish an assisted living or residential care residence as a home, rather than strictly a clinical facility.
When the word "community" is used in this manual it is referring to the care setting, not the community at large. Clarification will be provided if necessary. In some cases, such as when quoting from regulations, the term facility will be used.
Caregiver This is the person providing care. Although there are exceptions, typically this person is not a licensed medical professional.
Designated Many of the policies in this manual will refer to the "designated
Representative representative." It is recommended that you replace this title with the specific title of the individual(s) within your community that are responsible for the policy or procedure being described.
Licensee This is the person or organization that has obtained a license to operate the assisted living or residential care community from the appropriate state agency. In some cases the administrator and licensee is the same person.
Nurses Some policies and procedures in this manual refer to a nurse, if your community does not utilize nurses, modify the policies and procedures accordingly.
Physician Many policies in this manual recommend obtaining a "physician order" or prescription. In many states and situations the order or prescription can also be written by a Nurse Practitioner (NP) or Physician's Assistant (PA).
Resident The resident is the individual receiving care. In other healthcare settings the term "patient" or "client" are more common, but to foster a homelike atmosphere the term resident is used in the assisted living and residential care industries.
Responsible Most residents living in assisted living or residential care
Party communities will have a responsible party. This may be a family member with power of attorney, conservator, or another individual or agency that is legally authorized to make decisions on behalf of the resident.
If any of these terms conflict with those used by your organization you can use the electronic version of the manual on the accompanying CD-ROM to make necessary changes.
Assisted Living
Policy and Procedure Manual
General Policies
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POLICY: |
Personal Property/Theft and Loss |
This Theft and Loss Policy and Procedure program will be reviewed twice a year by all staff.
Personal Property
1. General
a. Residents will be encouraged to keep no more than $50.00 cash at any time.
b. Residents will be requested to keep fine jewelry and other items of value in a safe deposit box at their banking institution.
c. No items of value will be entrusted to the community for safe keeping and no cash or other moneys will be entrusted to the community.
d. The community does not have a safe on the premises to allow for safe keeping of residents’ valuables. Residents are encouraged to use their own private banking institution to provide this service. The community provides all rooms with either a lockable door to which the resident has a key, and/or a lockable cabinet to which the resident has a key.
2. Inventory
a. The community maintains a current inventory of all personal property identified by residents, unless the resident is able to secure his/her room or refuses the inventory and the refusal XE "Refusal" is documented.
b. When the inventory is complete, copies will be distributed to and kept by the community, the resident, and the resident’s responsible party.
c. The resident and responsible party are asked to notify the community of any additions to, or removal of, personal property inventory. The community will document XE "Documentation" appropriately.
d. In the event of a resident’s discharge or a resident’s death XE "Death" , the inventory list will be verified and the personal items will be packed. When the items are returned to the resident’s responsible party the list will be re-verified and signed in receipt of belongings.
3. Identification
a. Upon admission XE "Admission" , all residents will be requested to appropriately label all clothing and personal items.
b. All clothing will be labeled in an inconspicuous area (such as the clothing tag) with permanent laundry markers to clearly identify which resident they belong to.
c. All personal belongings that can be marked with permanent pen will be marked in discreet locations.
d. In cases where the item or items cannot be safely labeled with a non-erasable marker an electric pencil will be used to engrave the resident’s name in a discreet place on the items, if the resident agrees.
Theft and Loss
1. The community documents and appropriately investigates XE "Documentation" all alleged and actual theft and loss of personal property.
2. Residents are encouraged to notify staff immediately if they notice a personal item is missing.
a. Staff will conduct a thorough search for the missing item(s).
b. If the personal belongings cannot be found, an estimate of their value will be assessed. The estimate will be the original purchase price plus or minus any appreciation or depreciation that has occurred.
c. If the theft exceeds $100.00 or more, a report shall be filed with the appropriate local law enforcement agency.
d. All appropriate documentation of the incident will be given to the responsible parties.
i. The community will maintain the records on file for a minimum of three (3) years after the theft.
Notification
1. The community notified all appropriate parties about the theft and loss prevention program and provides them with copies of applicable laws.
2. The community posts the policy and procedures for safeguarding the residents’ property in a common area accessible to all residents and visitors.
3. Upon moving into the community, the resident and appropriate parties will be notified verbally and given a copy of the theft and loss policy.
4. Copies of these procedures and applicable laws are available to anyone upon request.
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POLICY: |
Abuse, Fraud, and Wrongdoing |
The community takes all reasonable steps to prevent resident abuse and neglect.
Residents, their responsible parties, personnel, health professionals and all relevant stakeholders are encouraged to report in good faith any activity, policy or practice, fraud, abuse and any other wrongdoing that he/she believes violates professional standards of practice or is against the law, or poses a substantial risk to the health, safety, welfare or rights of a resident.
Residents, their responsible parties, personnel, health professionals and all relevant stakeholders may report such activities, policies or practices without fear of restraint, interference, coercion, discrimination or reprisal. Reasonable efforts are made to maintain the confidentiality of the resident, their family, personnel, healthcare professional or relevant stakeholders.
The Administrator will investigate any reports of abuse, fraud, or other wrongdoing.
Procedure
1. All staff will receive training on elder abuse incidence, signs and symptoms, and reporting requirements.
2. Residents, their responsible parties, personnel, health professionals and all relevant stakeholders are encouraged to report any suspected incidence of abuse, fraud, or other wrongdoing.
3. If a report of abuse, fraud, or other wrongdoing is received:
a. The Administrator is notified immediately
b. Any urgent medical or safety issues are addressed immediately.
c. The Administrator or other designated representative initiates and investigation.
d. The resident's responsible party is notified.
4. If the suspected abuse, fraud, or other wrongdoing is substantiated a written report is made to the appropriate licensing/regulatory agency, the responsible party XE "Family/Responsible Party" , the Ombudsman, and Adult Protective Services.
5. All appropriate parties are notified of the outcome of the investigation.
6. Appropriate disciplinary actions will be made if community staff participated in substantiated abuse, fraud, or other wrongdoing.
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POLICY: |
Personal Care Attendants |
Residents who desire to use a personal care attendant for extended periods of time may do so with the prior approval of the administrator XE "Administrator" .
Procedure
1. Resident needs may require a personal attendant, but must not require 24 hour skilled nursing care.
2. Personal Care Attendants from outside agencies may be used if approved by the Administrator XE "Administrator" . The agency shall ensure a criminal clearance on all staff, health screening, appropriate insurance including liability and worker’s compensation, proof of appropriate employer tax obligations, including but not limited to withholding of state and federal taxes, payment of disability and unemployment insurance. All appropriate labor laws are to be followed and the Personal Care Attendant supervised by an agency Administrator familiar with this assisted living community operations.
3. All Personal Care Attendants from outside agencies are to be fully trained in all necessary care giving skills by the agency prior to coming in the assisted living community to serve a resident.
4. Personal Care Attendants may not perform any act not allowed by regulation or law.
5. The Personal Care Attendant, if employed by an agency, is expected to notify his/her supervisor and community staff of any change in resident status.
6. The Personal Care Attendants, if employed by an agency, are not to provide care at any time to any other resident in the community.
7. It is the responsibility of the agency to ensure proper training of the Personal Care Attendant employed by the agency in emergency procedures such as fire evacuation, disaster preparedness, etc.
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Home Health Agencies |
Residents may receive services from a Home Health Agency. Services will be coordinated by the community Administrator or designated representative.
Procedure
1. Verify appropriate physician orders for the use of a Home Health Agency.
2. The Administrator XE "Administrator" provides clarification of the scope of practice in an assisted living community (e.g. prohibited conditions, etc.), as well as community policies regarding privacy, sign-in/sign-out, reporting suspected abuse, etc.
3. The community Administrator, resident, and other appropriate parties will be involved in the development of the Home Health Agency plan of care.
4. Home Health Agency staff are expected to check-in with the Administrator XE "Administrator" when arriving at the community and when leaving.
5. The Home Health nurse XE "Administrator" should notify the Administrator of any significant change in a resident's condition/services to provide continuity of care and to allow for monitoring of prohibited or restricted conditions.
6. The Administrator XE "Administrator" shall make the Home Health Agency aware of all new orders, medication XE "Medications" changes and response to interventions performed by community staff.
7. The home health agency is expected to give notice to the resident of the time of the visit.
8. A home health agency shall not provide training nor expect a non-licensed XE "Unlicensed Staff" care giver to perform any prohibited act/service in the community. Examples of prohibited acts include, but are not limited to:
a. Non-licensed XE "Unlicensed Staff" staff filling insulin syringes.
b. Dressing changes.
c. Wound irrigation.
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Motorized Mobility Devices |
Residents using motorized mobility devices, also known as scooters, are asked to ensure the safety of all by observing the following rules.
Procedure
1. Written physician approval/authorization shall be received for each resident using a motorized mobility device.
2. Carts are to be parked in the resident room or patio when not in use.
3. Carts are to be driven on the right side of hallways whenever possible.
4. Extreme caution is to be used when pulling out around blind turns, corners, etc..
5. Carts are to be kept a safe distance behind all pedestrians, following the manufacturer's guidelines for safe stopping distances.
6. Utmost courtesy is used to prevent rushing other residents on foot, in wheelchairs or using other types of mobility aids.
7. Never drive carts when under the influence of alcohol or medications XE "Medications" that could pose a safety hazard, anywhere on the premises.
8. Caregivers will assist residents into any areas not safely accessible by carts
9. In community rooms, carts should enter first and be the last to exit, unless otherwise instructed for resident safety.
10. Always keep carts in good repair to ensure safety.
11. Appropriate insurance is to be carried by all cart drivers/owners with minimum coverage in the amount designated by community.
12. Carts are to be driven on the lowest possible speed at all times when indoors.
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Resident Transportation |
Resident transportation needs will be met.
Procedure
1. Before Transporting
a. Post notices of scheduled transportation in a clear, easy to read format. Explain schedules to visually or other disabled residents.
b. Ensure special arrangements are made for residents with special needs.
c. Resident’s families are asked to place transportation requests a minimum of 36 hours prior to the appointed time.
2. For Resident Safety
a. Residents are to have the cognitive and physical ability to be transported without assistance. This is to be verified by a physician XE "Physician" statement. Otherwise, residents are not allowed to be transported without assistance.
b. Should a resident require accompaniment/assistance of any kind, the Administrator XE "Administrator" arranges such assistance prior to transportation of the resident.
c. Community vehicle drivers are to be notified verbally and in writing of all residents who are not safe to leave the building without an escort.
3. All community drivers are to be appropriately licensed, in good health, drug free and safe to operate a motor vehicle.
4. A safety check of the vehicle is to be performed by the driver before operating the vehicle.
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Resident Independent Departure Assessment |
Residents will be appraised for the ability to depart the community independently.
Procedure
1. Each resident will have a physician XE "Physician" verification of the ability to leave unescorted.
2. Should a physician XE "Physician" not concur that the resident is able to leave without an escort the resident will be encouraged to have staff accompaniment on outings.
a. This is documented in the resident's record, and the responsible party if notified.
3. Eviction will be considered for residents who are not safe to leave without supervision, yet insist on leaving independently.
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POLICY: |
Sign-In/Sign-Out |
Residents are asked to sign-in and out when arriving at and leaving the community.
Dementia XE "Dementia" Note: Should the community serve residents with dementia a more appropriate policy would be necessary.
Procedure
1. Residents are asked to sign out when leaving the community. The person accompanying the resident is noted as well as the time.
2. Residents may not be required to disclose their destination. However, for safety purposes the resident’s destination may be recorded if it is voluntarily disclosed.
3. Residents leaving for extended periods should notify the front desk.
4. If residents are out during meal time, it is requested that staff be notified that the resident will be out.
5. Upon returning to the community, resident or staff may sign them in.
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Firearms |
To ensure the safety of residents and staff firearms and ammunition are not permitted within any part of the community.
Procedure
1. Prior to admission, residents will be informed of the prohibition of any firearm or ammunition within any part of the community.
2. On admission the resident and or responsible party, as appropriate will be asked if any firearm is being brought into the building.
3. Should a staff member suspect or identify a firearm or ammunition is present in the community, their immediate supervisor is to be notified immediately.
a. The Administrator will be notified by the supervisor and appropriate steps will be taken to remove the firearm.
b. If the resident refuses to allow the firearm to be removed, or at anytime staff or resident safety is in danger, the police or sheriff will be notified immediately by calling 9-1-1.
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POLICY: |
Personal Rights |
Staff will observe and respect the personal rights of all residents residing in the community.
Procedure
Staff respects each resident’s personal rights, which include, but are not limited to, the right:
1. To be accorded dignity in his/her personal relationships with staff, residents, and other persons.
2. To be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination.
3. Leave or depart the community at any time and to not be locked into any room, building, or on community premises by day or night.
4. To visit the community prior to residence along with his/her family XE "Family/Responsible Party" and responsible persons.
5. To have his/her family XE "Family/Responsible Party" or responsible persons regularly informed by the community of activities XE "Activity" related to his care or services including ongoing evaluations, as appropriate to the resident's needs.
6. To have communications to the community from his/her family XE "Family/Responsible Party" and responsible persons answered promptly and appropriately.
7. To be informed of the community's policy concerning family XE "Family/Responsible Party" visits and other communications with residents.
8. To have his/her visitors XE "Visitors" , including ombudspersons and advocacy representatives permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
9. To wear his/her own clothes; to keep and use his/her own personal possessions, including his/her toilet articles; and to keep and be allowed to spend his/her own money.
10. To have access to individual storage space for private use.
11. To have reasonable access to telephones XE "Telephone" , to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.
12. To mail and receive unopened correspondence in a prompt manner.
13. To receive or reject medical care, or other services.
14. To receive assistance in exercising the right to vote.
15. To move from the community.
16. To have the freedom of attending religious services or activities XE "Activity" of his/her choice and to have visits from the spiritual advisor of his/her choice.
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POLICY: |
Dignity |
Each resident has the personal right to be accorded dignity in his/her personal relationships with staff, residents, and other persons.
Procedure
1. Staff are respectful and courteous in all interactions with residents.
2. Staff refer to residents by proper name (e.g. Mr. Smith or Mrs. Jones), unless requested to use another name by the resident or responsible party XE "Family/Responsible Party" .
3. When addressing personal care needs (e.g. bathing), staff will speak with residents in a private location.
4. Privacy is provided to avoid creating a sense of humiliation or embarrassment for a resident.
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POLICY: |
Corporal Punishment and Restraints |
Each resident has the personal right to be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination.
Procedure
1. Corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature are never used in caring for a resident.
2. Physical or chemical restraints of any kind are never used in this community.
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Complaints |
Each resident has the personal right to be informed by the administrator XE "Administrator" (or a designated representative) of provisions of law regarding complaints and of procedures to confidentially register complaints, including, but not limited to, the address and telephone XE "Telephone" number of the complaint receiving unit of the licensing agency.
Procedure
1. At the time of admission XE "Admission" the administrator XE "Administrator" (or a designated representative) informs the resident and his/her responsible party of the internal community complaint policy and procedure.
2. At the time of admission XE "Admission" the administrator XE "Administrator" (or a designated representative) informs the resident and his/her responsible party XE "Family/Responsible Party" of the desire by the community and all community to accommodate resident requests, needs, complaints, and concerns.
3. At the time of admission XE "Admission" the administrator XE "Administrator" (or a designated representative) provides the resident and his/her responsible party XE "Family/Responsible Party" a method of contacting the Ombudsman.
4. At the time of admission XE "Admission" the administrator XE "Administrator" (or a designated representative) informs the resident and his/her responsible party XE "Family/Responsible Party" of provision for registering complaints with the state licensing agency. This includes, at a minimum, the address and telephone XE "Telephone" number of the complaint-receiving unit of the licensing agency.
5. Caregivers bring all resident requests, concerns, and/or complaints to the attention of his/her immediate supervisor or the administrator XE "Administrator" .
6. The administrator XE "Administrator" (or designated representative) investigates all complaints and discusses his/her findings with the resident and his/her responsible party XE "Family/Responsible Party" .
7. The administrator XE "Administrator" (or a designated representative) reports all substantiated serious or repeated complaints to the local state licensing agency (as required by state regulation).
Assisted Living
Policy and Procedure Manual
Staffing
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Staffing Introduction |
This section includes sample staff position titles, job descriptions, duty schedules and forms used for communication with and between employees.
The manual uses the title Resident Care Coordinator for a supervisory position for the Caregivers. Other titles commonly used for this position include:
· Assisted Living Director
· Director of Resident Services
· Director of Assisted Living
· Supervisor of Personal Care
· Shift Supervisors
This manual refers to the direct care providers in the assisted living community as Caregiver. Again, there are other common names also used within this industry such as:
Care Givers
Care Aids
Resident Aids
Personal Care Assistants
Resident Attendants
Certified Nurses Aids (only with proper certification)
Choose what fits your community best and make necessary changes to this manual.
In this employee section there exists some “universal staffing,” in that you will see Caregivers performing some housekeeping duties. The idea of cross training may be greatly extended in your community or you may prefer a more narrowly defined job role than what is described within these pages. There exists tremendous flexibility within the assisted living and residential care industry to staff in a manner which reflects the best standard of care based on your resident population, size of community, and other factors. When working within an assisted living community, the staffing patterns should reflect the needs of your senior population.
This section is not intended as an exhaustive human resources reference, but rather focuses on resident care issues and the providers of the direct care services. In your community you will likely have addendum support staff in other departments for such services as housekeeping, food services, groundskeepers, maintenance, financial operations, etc.
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Staff Training |
Direct care staff will Residents will receive initial orientation and ongoing inservice training based on state regulations and the needs of the residents being served in the community.
Implementation
1. Training on the following topics is included during caregiver orientation training and ongoing inservices.
a. Professional and ethical conduct, confidentiality, and reporting requirements.
b. Promoting resident dignity, independence, privacy, self-determination, choice and resident rights.
c. Abuse, neglect, exploitation and reporting requirements.
d. Fire, safety and emergency procedures, including identification of unsafe environmental factors.
e. Infection control and Standard Precautions.
f. Emergencies, evacuations, disasters, incident reporting,
g. Advanced directives and Do-Not-Resuscitate Orders.
h. Psychosocial care and social, recreational activities.
i. Diversity: cultural, age, gender, sexual orientation, spiritual beliefs, socioeconomic status, language, ethnicity, racial issues, etc.
j. End of life care and ethical issues.
k. Special care needs, aging issues, age-related limitations.
l. Providing physical care, assisting with ADLs, encouraging independence, lifting and transferring techniques, use of care equipment (e.g. lifts).
m. Nutritional issues.
n. Documentation and recordkeeping.
o. Service plans, assessments, appraisals, resident summaries, person-centered care, and end of shift reports.
p. Dementia care, managing behavioral challenges, wandering and elopement (as applicable).
q. First Aid and CPR (as applicable).
r. Medication management (as applicable).
2. All training will be documented. Copies of documentation will be retained in the employee record.
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Job Description: Administrator |
Department: Administrative
Reports to: Licensee
Description of Position:
The Administrator XE "Administrator" is fully responsible for community operations and quality of care. Financial stability of the community, staffing practices and day to day operations are coordinated by the Administrator to fall XE "Falls" within the operational guidelines of governmental agencies. The Administrator structures the environment which will produce the highest standards of non-medical care.
Responsibilities of the Administrator XE "Administrator" :
1. Identify and develop community standards of care congruent with the population seeking placement.
2. Project and develop a sound operating budget for the community.
3. Standardize operations of each department.
4. Maintain the community in compliance with regulatory agencies.
5. Develop sound policy and procedure for resident care.
a. Utilize a system of sound management which monitors quality standards on an ongoing basis in all departments.
6. Develop and carry out a successful marketing program which maintains > 95% occupancy.
7. Approve all admissions XE "Admission" .
8. Hire new staff and/or terminating of unsatisfactory staff.
9. Investigate theft/loss in the community.
10. Carry out the operating policy of the licensee.
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POLICY: |
Job Description: Assistant Administrator |
Department: Administrative
Reports Directly to: Administrator XE "Administrator"
Description of Position:
Provides direct supervision of department heads. Works with the community, ensuring that the community is a positive choice for seniors in the area. Coordinates all departments to promote outstanding community operations in alignment with goals, budget guidelines and resident needs. Assumes responsibilities of the administrator XE "Administrator" in his or her absence, following community guidelines. Supervises operations to conform to regulatory guidelines.
Responsibilities of the Assistant Administrator XE "Administrator" :
1. Supervise all department heads to ensure community is operating according to standards and in compliance with regulatory guidelines.
2. Implement department budget and approve or deny expenditures based on the allocations set by the Administrator XE "Administrator" .
3. Work within the community to place residents in need of a higher level of care.
4. Market the community to prospective placements. Schedule and plan all community outreach projects.
5. Coordinate move-ins with other department heads.
6. Assume full responsibility all regulatory guidelines forms and documentation XE "Documentation" for residents and employees and ensure that administrative operation is up to date and complete at all times. Secure all admission XE "Admission" paperwork prior to move-in.
7. Organize monthly resident and family XE "Family/Responsible Party" council meetings as well as family conferences.
8. Prepare all licensing requests for exceptions XE "Exception" , waivers XE "Waiver" and exemptions for Administrators review and signature.
9. Monthly review of vendor performance.
10. Initial screening for all new job applicants. Verify qualifications.
11. Criminal clearances and coordination of pre-employment documentation XE "Documentation" .
12. Coordinate employee performance reviews.
13. Investigate complaints, document XE "Documentation" and review with administrator XE "Administrator" .
14. Terminate unsatisfactory staff with approval from administrator XE "Administrator" .
15. Other duties as assigned.
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Job Description: Resident Care Coordinator |
Department: Resident Care Services
Reports to: Administrator XE "Administrator"
Description of Position:
The Resident Care Coordinator works as a liaison between residents, resident families, and staff. The Personal Care Coordinator’s duties also include problem solving resident concerns and coordinating care with the Caregivers. The Personal Care Coordinator may be an RN or LVN when necessary.
Staffing Pattern:
The community has one Personal Care Coordinator position, on days only. This is the chief supervisory position for the Caregivers who provide primary care to their resident assignment.
Responsibilities of the Personal Care Coordinator:
1. Caregiver scheduling and resident assignments, working within the department allowances.
2. Coordinate admissions XE "Admission" with assistant administrator XE "Administrator" including supervising move-ins to be sure accommodations are as desired and care is immediately implemented.
3. Family XE "Family/Responsible Party" /resident admission XE "Admission" interviews.
4. Immediately bring prohibited conditions or at-risk residents in need of a higher level of care to the attention of the assistant administrator XE "Administrator" .
5. Coordinate care planning with home health agencies on site, working within community policy.
6. Arrange for transportation as desired by the resident.
7. Arrange for resident special needs involving other departments, verifying follow through.
8. Function as a liaison with families ensuring special needs/requests/complaints are addressed. Inform assistant administrator XE "Administrator" , in writing and verbally, of all family XE "Family/Responsible Party" or resident complaints.
9. Monitor staff performance, providing or arranging assistance as needed.
10. Read all communication notes regarding the community between the Caregiver shifts.
11. Coordinate staff training and in-service schedules with the Assistant Administrator XE "Administrator"
12. Supervise the medication XE "Medications" room and orders, working with and supervising Medication Aides and Caregivers.
13. Other duties as assigned.
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Job Description: Medication Aide |
Department: Resident Care Services
Reports to: Personal Care Coordinator
Description of Position:
Coordinates resident care related to medications by working with all departments, the medical community, families and administrative staff to provide for resident needs with continuity and an adherence to the scope of practice and licensure for the community. Provides complete supervision of the medication XE "Medications" room, pass techniques, documentation XE "Documentation" and supervision and provision of care related to medication in the community.
Staffing Pattern:
The community has one Medication XE "Medications" Aide on each shift.
Responsibilities of the Medication XE "Medications" Aide:
1. Resident charts. Keeping documentation XE "Documentation" current (Community forms, licensing documentation, physician XE "Physician" orders, incident reports., etc.)
2. Communicate resident status changes XE "Administrator" .
3. Ensure all medication XE "Medications" documentation XE "Documentation" is current and correct, including medication administration forms, physician XE "Physician" orders, change of dosages, written orders to confirm telephone XE "Telephone" orders, etc.
4. Ensure medication XE "Medications" room is completely stocked with all required continuous, PRN XE "Medications:PRN" , Over-the-Counter (OTC), and other XE "Medications:Over-The-Counter" medications as ordered by the physician XE "Physician" .
5. Coordinate medication orders and deliveries with pharmacies
6. Communicate with physicians and other healthcare providers as needed.
7. Monitor Psychotropic med use is congruent with physician XE "Physician" orders and ensuring resident behaviors actually warrant the use of medication XE "Medications" .
8. Control medication XE "Medications" room access and key assignment.
9. Pour, pass, and assist with administration of medications in accordance with state regulations XE "Medications" .
10. Coordinate physician XE "Physician" and other medical appointments.
11. Read all communication notes regarding the community between the Caregiver shifts.
12. Other duties as assigned.
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Job Description: Caregiver |
Department: Resident Care Services
Reports Directly to: Personal Care Coordinator
Description of Position:
Provides direct personal care and supervision to the residents at the community. Promotes resident well being and satisfaction through support with activities XE "Activity" of daily living XE "Activities of Daily Living" . Communicates with other departments to ensure resident needs are met.
Staffing Pattern:
The Resident Care Services department at this assisted living community staffs through a primary care structure. Each Caregiver will be charged with all of the personal care duties of their resident assignment. Whenever possible each Caregiver will be assigned to the same resident group each day to promote continuity of care.
Responsibilities of the Caregiver:
1. Assist with activities XE "Activity" of daily living XE "Activities of Daily Living" , including passing medication XE "Medications" as assigned, following community protocol, licensing regulation and guidelines for both resident and employee safety.
2. Follow safety guidelines in the community, including proper lifting technique and universal precautions when providing care to the residents.
3. Follow the schedule of duties for the Caregiver, as well as the individual plan of care for each resident.
4. Function as a team, assisting coworkers as the need arises.
5. Monitor resident activity XE "Activity" , food intake, functional status, psychosocial XE "Psychosocial" status, taking action as required to promote resident well being.
6. Report status change immediately to the supervisor.
7. Act immediately on any resident crisis XE "Crisis" , following protocol and basic first aid training.
8. Document XE "Documentation" resident status change, including but not limited to, physical change, reaction to medication XE "Medications" , psychosocial XE "Psychosocial" status change.
9. In the event all assigned duties cannot be completed, ask for assistance and report to the personal care coordinator.
10. Any other assignments made by your direct supervisor or administrator XE "Administrator" .
11. Promote open communication between health care professionals, families, residents and staff.
12. Adhere to guidelines in the employee handbook including dress code, conduct, scheduling, etc.
13. Other duties as assigned.
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Volunteers |
Students and/or volunteers will be utilized as appropriate. Procedures will ensure the safe, competent and mutually beneficial performance of volunteers.
Implementation
1. Signed Agreement
a. All volunteers will sign a written volunteer agreement.
2. Job Functions
a. Volunteers work under the direct supervision of the Director of Activities.
b. Job functions will be specified by the Director of Activities for each volunteer.
c. Job functions may include: assisting with activity programs, assisting during activity outings, organizing activity supplies, arranging for outings and special events.
d. All job functions will adhere to state-specific regulations.
3. Scope of Responsibility
a. Volunteers will not be assigned responsibility to supervise community staff, caregivers, nurses, etc.
b. Volunteers are responsible for ensuring the safety, well-being and personal rights of residents involved in their activities.
4. Criteria for Use/Supervision
a. Use of volunteers will adhere to state-specific regulations.
b. Volunteers are under the direct supervision of the Director of Activities.
5. Orientation and Training
a. Volunteers will receive necessary orientation and training from the Director of Activities.
b. Orientation and training will address:
i. Introduction to program and philosophy.
ii. Volunteer responsibility.
iii. Attendance.
iv. Reporting.
v. Safety.
vi. Delayed egress and/or alarm systems (if applicable).
vii. Confidentiality.
viii. Abuse reporting.
ix. Overview of resident-specific care or health issues.
6. Dismissal
a. Volunteering is at the mutual consent of the community and the volunteer. Either party may terminate the relationship at any time, with or without cause and with or without advance notice.
7. Confidentiality
a. Volunteers will respect and ensure the confidentiality of all resident, staff and community information.
Assisted Living
Policy and Procedure Manual
Admissions and Move-In XE "Admission"
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Resident Pre-Admission XE "Admission" Appraisal XE "Appraisals" |
The Administrator XE "Administrator" will gather data on each potential resident to determine the need and type of services to be provided.
Procedure
1. The Administrator XE "Administrator" meets with the resident and responsible party XE "Family/Responsible Party" prior to admission.
2. The Resident Appraisal XE "Appraisals" is completed by the Administrator.
3. The Administrator XE "Administrator" begins the pre-placement meeting with proper introductions and explanations to promote a milieu of trust, comfort, and honesty. Open-ended questions are encouraged. Consent is obtained for the appraisal XE "Appraisals" .
4. The purpose of the appraisal XE "Appraisals" is explained: to determine the level and type of services/care needed by the resident and that will be available for the resident at the time of move-in, as well as to meet state licensing requirements. The resident and/or family XE "Family/Responsible Party" is assured by the Administrator that honesty and detail regarding care needs is in the best interest of the resident.
5. Communicate acceptance by use of proper body posture, nods of understanding and allowing the resident ample opportunity to answer questions.
6. The Administrator XE "Administrator" reviews the Physician XE "Physician" Report for any prohibited conditions or communicable illness.
7. Absence of TB XE "Tuberculosis" must be evidenced by a physician report or chest x-ray within the last six months.
8. The resident and/or responsible party XE "Family/Responsible Party" are questioned about skin XE "Skin" breakdown XE "Physician" .
9. A medication XE "Medications" review will include the following:
a. Review of all medications on hand or reported.
i. NOTE: A physician XE "Physician" order is to be obtained prior to admission XE "Admission" day, verifying medications XE "Medications" and dosing schedule.
b. Specifically ask about the use of OTC XE "Medications:Over-The-Counter" (Over-The-Counter) medications and complimentary or alternative medicines XE "Medications" . Note any preferred OTC medications to ensure physician XE "Physician" orders are secured prior to admission XE "Admission" .
i. NOTE: This is an opportunity for resident teaching regarding the storage and use of OTCs, related to regulatory guidelines.
c. Should a resident desire to retain his/her OTC XE "Medications:Over-The-Counter" medications XE "Medications" , a physician XE "Physician" order is obtained indicating the resident may self-store and self-administer medications.
d. When OTC XE "Medications:Over-The-Counter" medications XE "Medications" are centrally stored, a physician XE "Physician" order is required for all routine medications prior to assisting with the medication.
e. When the OTC XE "Medications:Over-The-Counter" is a PRN XE "Medications:PRN" and centrally stored, the following must be included in the physician XE "Physician" order:
i. Name of drug
ii. Strength of drug
iii. Dosage
iv. Exact time frames between doses
v. Maximum dose in a 24 hour period
vi. Symptoms for which the medication XE "Medications" is used
10. Information regarding alcohol consumption is obtained.
11. Prohibited health conditions XE "Health condition:Prohibited" and/or residents significantly at risk are identified. See the policy on prohibited health conditions for more information.
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Allowable Health Conditions |
The community will admit and retain stable residents with health conditions that can be safely cared for by community staff and are in compliance with state licensing agency guidelines.
Procedure
1. A physician's XE "Physician" report XE "Physician’s Report" is reviewed prior to placement to verify diagnoses and health conditions.
2. The Physician XE "Physician" Visit form is used to monitor health status changes after the resident is admitted.
3. The following are examples of health conditions/needs that may be managed in the community.
a. Use of oxygen XE "Oxygen" when blood gases are stable and the resident is capable of self-administration.
b. Colostomy, when the resident is able to manage all aspects of the condition XE "Ostomy: Colostomy" .
c. Ileostomy, when the resident is able to manage all aspects of the condition XE "Ostomy: Colostomy" XE "Ostomy: Ileostomy" .
d. Incontinence XE "Incontinence" (both bowel XE "Bowel" and bladder XE "Bladder" ).
e. Stage I and II decubitus XE "Skin:Breakdown" ulcers.
f. Post-surgical wounds when the wound is well approximated.
g. Diabetes, including insulin-dependent, providing the resident has reasonable stability, and is able to self-test and self-inject.
h. Inhalation therapies.
i. Hospice XE "Hospice" , providing a Medicare certified hospice agency, contracted by the resident/responsible party XE "Family/Responsible Party" , is coordinating the care.
i. CALIFORNIA: A waiver XE "Waiver" must be obtained prior to providing care to residents receiving hospice services. Community Care Licensing XE "Community Care Licensing" must be notified in writing, within 5 days of the initiation of hospice services for any resident.
4. Mild to advanced dementia XE "Dementia" , providing the community is appropriately licensed.
5. Before accepting or retaining a resident with any of the above allowable health condition, an assessment/evaluation of the resident XE "Health condition:Allowable" must be completed to confirm:
a. Resident's ability for self-care.
b. Compliance with the care routine to maintain medical stability and consent to additional services whether by the community staff or outside contracting agencies.
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Day of Admission/Move-In |
The resident’s needs are addressed during the move-in process.
Procedure
1. The Administrator XE "Administrator" coordinates the following on move-in day to ensure appropriate resident care.
a. All preadmission documentation XE "Documentation" is complete and in the resident’s chart.
i. The chart is appropriately labeled and organized.
b. The service plan XE "Service plan" is completed.
c. All physician XE "Physician" admission XE "Admission" orders are received.
d. Medications
i. All new prescriptions are sent to the pharmacy for same day delivery, or if using existing fills, medications XE "Medications" are verified.
ii. The medication XE "Medications" cart/storage area is labeled and organized.
iii. The MAR XE "Medications:Medication Administration Record" (Medication XE "Medications" Assistance Record) is set up, including resident photograph in place.
e. Caregivers are assigned to assist the resident to put belongings away and settle into his/her room.
i. The assigned caregiver checks with the newly placed resident every 4-6 hours for the first 24 hours of placement, unless otherwise requested by the resident.
5. The Administrator XE "Administrator" meets with the resident at the time of move-in for a brief safety survey of the room and to verify that the resident is stable.
6. The Administrator XE "Administrator" orients caregivers about the needs of the newly admitted resident on each shift.
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Change in Condition |
When a resident exhibits a change in condition, action will be taken to coordinate appropriate care.
Procedure
1. When a resident displays a change in condition, caregivers notify the Administrator XE "Administrator" .
2. If a change in status progresses to an emergency at anytime, call 911 XE "911" .
3. Examples of change in condition may include, but not be limited to:
a. Refusal XE "Refusal" of meals
b. Decreased mobility/range of motion XE "Range of Motion"
c. Change in patterns of elimination
d. Weakness
e. Decreased coordination
f. Change in level of consciousness XE "Consciousness"
g. Decreased communication/response
h. Decreased ability to communicate signs
i. Decline in cognitive function
j. Motor agitation or retardation
k. Hallucinations or other unusual behavior
l. Nausea
m. Vomiting
n. Elevated or subnormal temperature XE "Vital Signs:Temperature"
o. Wheezing
p. Shortness of breath or exertion
q. Complaints of pain XE "Pain" or discomfort
r. Edema or swelling
s. Change in usual range of vital signs XE "Vital Signs"
t. Reaction/side effect to medications XE "Medications"
u. Weight loss
v. Depressive behaviors
w. Falls
4. If there is an actual change in condition the resident’s physician XE "Physician" is notified. Always have the resident’s complete chart, list of meds, current vital signs XE "Vital Signs" (if available), and concise list of problems available when calling the physician.
5. If this is part of an ongoing problem and home health or hospice are following the resident, contact the home health or hospice nurse and explain the situation at hand.
6. Document XE "Documentation" the date and time of contacts, and with whom you spoke. Clearly document any new orders and repeat back to the physician XE "Physician" .
7. Immediately enter the new orders on the resident’s service plan XE "Service plan" and/or medication XE "Medications" administration record XE "Medications:Medication Administration Record" if the order pertained to medications.
8. Notify the resident’s responsible person of the change in status and action taken.
9. Keep the Administrator XE "Administrator" abreast of the resident’s response to the new orders.
10. Report the status change and new physician XE "Physician" orders to each shift.
11. If the resident status change results in a prohibited health condition XE "Health condition:Prohibited" , a conference will take place with the administrator XE "Administrator" to determine the resident’s suitability for retention. The administrator will file for an exception XE "Exception" if required.
12. If the resident requires skilled monitoring due to the status change, the Administrator XE "Administrator" consults with the physician XE "Physician" to obtain an order for home health.
13. The Administrator XE "Administrator" documents XE "Documentation" , schedules and follows through with any continuing physician XE "Physician" appointments and medical care.
14. If the resident status change is more than a transient problem, a resident care conference is arranged.
15. If the change in status involves a change in ambulatory status, the resident will be retained in a nonambulatory-approved room.
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Ongoing Resident Appraisals |
Residents are assessed/evaluated on an ongoing basis.
Procedure
1. Daily Evaluations
a. All staff members are encouraged to informally monitor residents on a regular basis throughout the course of normal daily activities, and to report any changes in condition that are identified.
2. One-Month Resident Appraisal
a. Resident will be formally assessed thirty days after admission XE "Admission" .
b. The Administrator XE "Administrator" meets with the resident and/or responsible party XE "Family/Responsible Party" to verify the resident’s needs are met.
c. The Administrator XE "Administrator" consults with other caregivers and staff to ensure the resident’s needs are met.
d. The service plan XE "Service plan" is updated as necessary.
3. Quarterly Resident Appraisal
a. Residents are formally assessed on a quarterly basis.
b. The service plan XE "Service plan" is updated as needed.
c. Rates are adjusted, congruent with care delivered, and in accordance with the terms of the admission agreement.
d. The Administrator XE "Administrator" consults with other caregivers and staff to ensure the resident’s needs are met.
4. Stakeholders
a. The following key stakeholders are encouraged to participant in resident appraisals and service plan updates:
i. The resident
ii. The Administrator
iii. The resident's responsible party
iv. Selected members of the community's care staff
v. Appropriate healthcare professionals (e.g., home health nurse, physical therapy, etc.)
vi. The resident's physician
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Activity Assessments |
The activity preferences of each resident will be determined to aid in the development of a resident-centered activity plan.
Procedure
1. The Administrator or a designated representative interviews the resident and his/her responsible party XE "Family/Responsible Party" regarding the resident’s personal activity XE "Activity" history and preferences.
2. The following domains should be addressed during the interview:
a. Gross motor activities
b. Daily living skills
c. Self-care activities
d. Crafts
e. Interest in social programs, games, music
f. Interest in large and small group participation
g. Social events
h. Community activities
i. Sensory enhancement, tactile stimulation
j. Outdoor activities, field trips
k. Family events
3. Use the Resident Activity XE "Activity" Assessment XE "Assessments" form to document the assessment.
4. Information from the assessment is used to develop a resident-centered activity plan and schedule.
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Admission Agreements |
Each resident (or responsible party) signs an admission XE "Admission" agreement prior to admission.
Procedure
1. The resident and his/her responsible party is provided a copy of the admission agreement prior to admission.
2. Prior to admission XE "Admission" , the administrator XE "Administrator" meets with the resident and responsible party XE "Family/Responsible Party" to discuss the agreement as well as all fees and the plan of care.
3. The admission XE "Admission" agreement must be signed prior to admission.
4. Resident are given thirty days notice of any subsequent changes to the agreement.
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Service Plans |
A resident-centered service plan is created and maintained for every resident. The purpose of the service plan is to provide a centralized coordination of the services that will be provided to each resident, based on his or her individual needs, abilities, and preferences.
Procedure
1. The Administrator XE "Administrator" , or a designated representative, develops a service plan XE "Service plan" for each resident prior to admission XE "Admission" .
2. The service plan is developed with assistance and review from:
a. The resident.
b. Family/significant other or responsible party.
c. The Administrator (or designee).
d. A registered or licensed nurse, if the resident is receiving nursing services, medication assistance, or is unable to direct self-care.
e. The resident’s case manager (if applicable).
f. The team may also include (at resident’s or responsible party’s request): community personnel, his/her physician, and other persons as requested.
3. The service plan should address, but is not limited to, the following:
a. Activities of Daily Living (ADLs).
b. Medication management and/or assistance required.
c. Physical needs related to illness/chronic disease management.
d. Psychosocial needs including activities
e. Behavioral challenges/needs
f. Spiritual needs.
g. Fall history and/or risk.
h. Nutritional needs such as help with eating or special diet.
i. Skin integrity issues.
j. Any need identified by the family or resident.
k. Activities.
l. Transportation needs.
4. A copy of the service plan is available to all staff for review.
5. A current copy of the service plan, signed by the resident and/or responsible party is retained in the resident’s record.
6. All direct care staff are encouraged to give input on service plan changes.
7. Formal review takes place:
a. Thirty days after admission XE "Admission" .
b. Quarterly.
c. Annually.
d. Upon significant change in resident status/condition.
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Resident Care Conference |
The resident care conference is intended to encourage a multidisciplinary approach to resident care planning that involves input from all relevant stakeholders.
Procedure
1. Purpose of Resident Care Conferences:
a. To identify individual resident needs.
b. To collaborate with all stakeholders in the coordination of optimal resident care, ensuring clear communication of the plan of care.
c. To evaluate effectiveness of previous interventions and current resident status.
d. To develop resident-centered interventions and methods of care for the individual resident.
e. To coordinate discharges/evictions for those residents at risk for transfer trauma XE "Trauma" .
2. Indications for Resident Care Conference:
a. Upon admission XE "Admission" of a new resident.
b. Upon readmission of a resident if there has been a change in status or previous functional abilities.
c. Resident is at risk of move-out or discharge.
d. Change in resident status or condition.
e. Annual resident appraisal and service plan review.
3. Attendees at the resident care conference may include, but are not limited to:
a. Administrator XE "Administrator"
b. Assistant administrator XE "Administrator"
c. Appropriate department heads.
d. The resident
e. The resident's responsible party XE "Family/Responsible Party"
f. Home health nurse
g. Other health care providers as appropriate (e.g., hospice, physical therapy, etc.)
4. Documentation XE "Documentation" /Information
a. Conferences are to be resident focused at all times. It is the responsibility of the administrator XE "Administrator" to have all of the following information available at the conference:
i. Resident’s history.
ii. A copy of the entire resident charting XE "Documentation:Charting" for the last 60 days.
iii. List of current medications XE "Medications" .
iv. Significant health history.
v. Incident reports.
vi. Current service plan.
vii. All other relevant history and information.
viii. Current MD XE "Physician" orders.
5. Suggest Conference Agenda
a. The conference general agenda is as follows:
i. Identify the resident.
ii. State purpose of conference (at risk, status change, etc.)
iii. Brief history.
iv. Current medications XE "Medications" & Physician XE "Physician" orders.
v. State chief problems/concerns.
vi. Discussion/identification of needs.
vii. Review/critique of previous interventions and plan of care.
viii. Discussion, revision and formulation of current plan of action.
ix. Interventions.
x. Identification of individuals to carry out each intervention.
xi. Schedule of follow up conference date (as necessary) to evaluate status and interventions.
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Move-Out |
Residents may move out of the community for a variety of reasons, such as increased need for healthcare services, a change in condition, or family/personal reasons. A move-out of the community (discharge) is conducted in a dignified manner to limit transfer trauma and to ensure that resident needs are met XE "Trauma" .
Procedure
1. The Administrator XE "Administrator" coordinates the timing of the move-out with the responsible party XE "Family/Responsible Party" and receiving community or new residence.
2. If ambulance transportation is necessary, it is arranged by the Administrator XE "Administrator" .
3. The Administrator XE "Administrator" assigns a staff member to assist resident with collecting and packing belongings, as needed.
4. The resident is dressed in appropriate street clothing if going by car. Gown, pajamas, etc., may be worn if going by ambulance.
5. The caregiver assigned to the resident ensures hearing aid, dentures XE "Dentures" , etc., are in place and appropriately accounted for.
6. The resident’s medications XE "Medications" are counted and packaged appropriately for transportation. The person receiving the medications upon transfer signs for their receipt, accepting and acknowledging responsibility for safekeeping.
7. All treatments and medication XE "Medications" given within the last 24 hours are indicated, and passed on to the new community.
8. A resident move-out summary is completed in the resident's record.
9. The resident's record is archived.
Assisted Living
Policy and Procedure Manual
Resident Care
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Basic Care Services |
Personal care will be provided to all residents on an individual basis according to findings from admission XE "Admission" appraisals XE "Appraisals" and subsequent re-appraisals.
All resident care is planned and delivered in a resident-centered manner, and personal service plans XE "Service plan" should address any individual resident needs.
Procedure
1. At the beginning of each shift, staff should familiarize themselves with resident status. Clear communication with staff from the previous shift, using the shift report and verbal exchange, ensures quality care.
2. Each resident is monitored on a routine basis. Check on residents every two hours, unless indicated otherwise on the resident’s service plan XE "Service plan" .
a. NOTE: Residents with confusion or a diagnosis of dementia XE "Dementia" should be checked on an on-going basis.
3. Incontinent care is given as necessary to residents requiring assistance every two hours. This includes nighttime hours, unless the physician XE "Physician" orders indicate otherwise.
4. Medications XE "Medications" are to be given according to physician orders and when possible according to the following general medication pass schedule.
a. Morning medication XE "Medications" pass: 7:30 A.M.
b. Mid-day medication XE "Medications" pass: 11:30 A.M.
c. Evening medication XE "Medications" pass: 4:30 P.M.
d. Bedtime medication XE "Medications" pass: 8:30 P.M.
e. A "two-hour window" ensures appropriate delivery of medications. Medications XE "Medications" may be passed one hour earlier or one hour later unless indicated otherwise by the physician or authorized prescriber XE "Physician" .
5. PRN XE "Medications:PRN" medications XE "Medications" are administered according to physician XE "Physician" orders, resident requests, and state regulations.
6. Residents are assisted with morning care as needed, which may include but is not limited to the following XE "Activity" :
a. Clothing selection.
b. Dressing.
c. Oral care.
d. Assistive devices, such as eye glasses, hearing aids, etc.
e. Shaving.
f. Cosmetics.
g. Hair care.
7. Residents are to have a full shower/bath according to their needs and preferences, and at least twice per week.
8. Residents needing a reminder or assistance with ambulation or escorts are to receive assistance to the dining room as needed for all three meals and snacks as necessary.
9. Each resident is to have his or her room tidied and bed XE "Bed" made each day if unable to do so independently. Complete cleaning of their quarters is performed by housekeeping staff on a weekly basis.
10. Residents are encouraged to select and attend activities. It is the responsibility of the Caregiver to remind the resident of upcoming activities throughout the day.
11. Residents receive assistance with bedtime/evening care as needed, which includes, but is not limited to the following:
a. Oral care.
b. Dentures XE "Dentures" in a labeled cup.
c. Assistance into night clothes.
d. Toileting.
e. Incontinence XE "Incontinence" care.
f. Safety check of the room.
g. Remove physical obstacles to the bathroom, and leave a low light on in the bathroom.
h. Room set to a temperature desired by/comfortable for the resident.
i. Monitor noise level. XE "Lighting"
12. Any unusual incident will be reported and documented. All pertinent information on the resident will also be documented and passed on to the following shift.
13. Resident status changes will be reported to the physician XE "Physician" and resident's responsible party XE "Family/Responsible Party" , in accordance with the policy on Change in Condition.
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Use of Assistive Devices and Ambulatory Aids |
The community promotes resident safety by allowing and encouraging the use of resident assistive devices and mobility aids.
Implementation
1. The physician report and any pre-admission documentation will be reviewed prior to placement, identifying resident need for assistive devices or mobility aids.
2. The resident and responsible party are interviewed regarding resident need for assistive devices or mobility aids.
3. Upon admission, the resident’s assistive devices and mobility aids are labeled with name and room number.
4. Upon admission, residents are instructed about use of devices/aids within the community:
a. Use in dining room.
b. Storage of devices for safety.
5. When a resident receives a new order for a mobility aid, the physician is contacted to request a physical therapy consult for resident teaching.
6. In the dining room or common areas where an activity may cause some congestion, resident’s mobility aids are moved to a designated area, once the resident is seated safely. Staff will return the device to the resident upon request, when the resident is ready to ambulate.
7. Any resident using a motorized scooter must demonstrate safe operation of the device to the Administrator. The Resident Care Coordinator also obtains a written order verifying the ability for safe operation from the resident’s physician. The resident must be re-evaluated for safety should any impaired operation take place.
8. Safe use of mobility aids and assistive devices is included in staff orientation.
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Hygiene and Grooming |
The resident’s hygiene and grooming needs are met while addressing the resident’s personal preferences and daily routine.
Implementation
1. The Resident and responsible party are interviewed prior to move-in to determine the resident’s preferences for the provision of hygiene and grooming care.
2. The resident’s physician report and appraisal are reviewed to identify resident needs and preferences.
3. Special care needs are addressed in the resident’s service plan.
4. Residents are showered daily if desired, and at a minimum twice a week. Exceptions are allowed for residents with special conditions or needs, such as skin disorders or certain disease processes.
5. Bed baths are given upon evidence of need. The Resident Care Coordinator approves bed baths to be given on a regular basis.
6. Refusal of necessary hygiene and grooming is reported by Caregivers to the Resident Care Coordinator and/or Administrator. Continued refusal of hygiene and grooming is noted in the narrative charting section of the resident’s chart, and the Administrator is notified for further action.
7. Resident autonomy is encouraged. Residents are not encouraged to accept services when there is evidence they are capable of providing self-care adequately.
8. Assistance is scheduled as indicated in the service plan.
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Dressing |
The resident’s need for assistance with dressing is met in accordance with the resident’s personal preferences.
Implementation
1. The resident’s physician report will be reviewed to determine if assistance is required.
2. Resident and family/responsible party are interviewed prior to move-in to determine the resident’s preferences for the provision of hygiene and grooming care.
3. Residents requiring assistance with dressing are encouraged to perform as much of the task as possible.
4. The resident is expected to select or participate in the selection of his/her clothing.
5. Residents are dressed in “street clothes” when in common areas of the community.
6. Residents are assisted with additional clothing changes throughout the day as needed.
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Sleep and Rest |
Sleep disturbances will be addressed to promote appropriate rest.
Procedure
1. Residents with insufficient or poor quality sleep are monitored and/or interviewed for possible causative factors. The Administrator XE "Administrator" and Caregivers monitor for:
a. Bedtime and waking times
b. Bedtime rituals
c. Type of bedclothes
d. Frequency and duration of awake time
e. Activities XE "Activity" usually performed in the early evening hours
f. Leisure activities XE "Activity"
g. Medications XE "Medications" taken
h. Perceived health status and satisfaction with life
i. Food or fluids consumed shortly before bedtime
j. Number of nightly trips to the bathroom
k. Frequency of need for pain XE "Pain" medications XE "Medications" or for help with toileting
l. Time spent out of bed XE "Bed"
2. The Administrator XE "Administrator" initiates changes in care to improve sleep, such as:
a. Maintain the same daily schedule for waking, resting, and sleeping.
b. Get up at the usual time even if the sleep has been disturbed or the bedtime change temporarily.
c. Establish a bedtime ritual and stick to it.
d. Exercise every day but avoid vigorous exercises at night.
e. Limit naps to one or two hours per day, at the same time each day.
f. Take a warm bath in late afternoon or early evening.
g. Avoid caffeine-containing beverages and products.
h. Practice relaxation methods such as deep breathing, music, rocking, massage, or reading calm materials.
i. Eat a light XE "Lighting" snack of carbohydrates and fat before bed XE "Bed" .
j. If the resident is awake for longer than 30 minutes, get the resident out of bed XE "Bed" and engage in a non-stimulating activity XE "Activity" such as reading.
3. When other methods have failed, the Administrator XE "Administrator" consults with the physician XE "Physician" for possible use of temporary sleep aids or other medical interventions or assessments XE "Assessments" .
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Incontinence |
Residents suffering with incontinence XE "Incontinence" will receive care and management aimed towards restoring continence whenever possible and preventing incontinence-related complications.
Procedure
1. Should a resident have an episode of incontinence XE "Incontinence" , the Administrator XE "Administrator" consults with the physician XE "Physician" to investigate the following:
a. Problems with manual dexterity or mobility.
b. Problems or changes in the environment (access, distance to toilets, etc.)
c. Problems with excessive fatigue.
d. Difficulty or painful voiding.
e. Problems with constipation/stool impaction.
f. Changes in diet, including increase in caffeine.
g. Changes in medications XE "Medications" , such as addition of a diuretic.
h. Changes in behavior/affect.
i. Mental status.
2. The Administrator XE "Administrator" instructs caregivers to track episodes of incontinence XE "Incontinence" . If the resident is alert XE "Alert" , encourage the resident to track episodes themselves.
3. The Administrator XE "Administrator" transmits the information on episodes of incontinence XE "Incontinence" and other pertinent information to the resident’s physician XE "Physician" .
4. The Administrator XE "Administrator" establishes a toileting schedule for staff to follow when appropriate.
5. The Administrator XE "Administrator" consults with the physician XE "Physician" to develop interventions to correct incontinence XE "Incontinence" whenever possible.
6. Should interventions fail and the resident is diagnosed with chronic intractable incontinence XE "Incontinence" , the service plan XE "Service plan" will include a skin XE "Skin" management plan.
7. Unless contraindicated, residents receive incontinent care and brief changes every two hours, or more often as needed, to keep the resident clean and dry.
8. Caregivers are instructed to monitor for and report any signs of skin breakdown.
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Nutrition and Weights |
The community monitors weights and provides modified diets as ordered by the physician XE "Physician" .
Procedure
1. The Administrator XE "Administrator" assigns the task of measuring resident weights to caregivers (after appropriate training) on a monthly basis.
2. Weights are measured more often if ordered by the physician XE "Physician" .
3. Weight measurements are recorded in the residents record on the weight record form.
4. Weights are measured using the following guidelines:
a. Prior to breakfast, after first voiding, and with the same amount of clothing each day.
5. A weight change of five pounds or 5% of body weight in a 30-day period, whichever is greater, is reported to the physician XE "Physician" .
6. Nutritional supplements will be offered to the resident as ordered by the physician XE "Physician" .
7. Modified diets will be provided as ordered by the physician XE "Physician" .
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Podiatry and Nail Care |
The community will arrange for or make available foot and nail care.
Procedure
1. Caregivers monitor the length and condition of the toe and finger nails of residents receiving bathing, dressing, or grooming services.
2. Caregivers note changes in residents’ nail or foot integrity.
3. Caregivers do not trim nails, smooth corns, calluses, etc.
4. The Administrator XE "Administrator" schedules a podiatry appointment for foot and/or nail care, other than cleaning or moisturizing.
5. The Administrator XE "Administrator" arranges for regular (monthly preferred) onsite visits by a podiatrist, as needed and as available.
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Caregiver Daily Schedule |
Caregivers are given assigned duties to ensure quality care.
This is only a basic policy and schedule. Always refer to the resident’s individual plan of care for additional intervention.
11:00 pm - 7:30 am
1. Verify resident status changes with the previous shifts. Read documentation XE "Documentation" .
2. Rounds every two hours.
3. Incontinent care every two hours as assigned, and as needed.
4. Housekeeping duties as assigned.
5. PRN XE "Medications:PRN" medications as needed (med aides only).
6. Awaken first serving breakfast residents.
7. Assist with designated early morning baths.
8. Assist as needed with grooming: Resident morning grooming (assist only as required)
a. Bathing (on designated days)
b. Incontinent care
c. Clothing selection
d. Dressing
e. Oral care
f. Assistive devices in place
g. Shave
h. Make-up
i. Hair care
j. Mini appraisal XE "Appraisals"
9. First serving residents to dining room.
10. Set-up and pass 7:30 am medications (medication aides only).
11. Assist second serving residents with personal care.
12. Document XE "Documentation" resident status change or incidents per community protocol.
13. Report off to next shift.
7:00 am - 3:30 pm STAFF DUTIES
1. Verify resident status changes with the previous shifts. Read documentation XE "Documentation" .
2. Check schedule for resident physician XE "Physician" or other scheduled appointments.
3. Designated resident baths.
4. Assist with resident grooming which was not completed by the night shift.
a. Bathing ( on designated days )
b. Incontinent care
c. Clothing selection
d. Dressing
e. Oral care
f. Assistive devices in place
g. Shave
h. Make-up
i. Hair care
j. Mini appraisal XE "Appraisals"
5. Second service residents to dining room by 7:30 am.
6. Rounds every 2 hours.
7. Incontinent care every 2 hours as assigned.
8. Make beds.
9. Tidy rooms/housekeeping duties as assigned.
10. Pass am snacks.
11. Residents to 10:00 am activities XE "Activity" .
12. PRN XE "Medications:PRN" medications as needed (med aides only).
13. Prepare and assist first serving residents to dining room for lunch.
14. Prepare and pass 11:30 am medications (med aides only).
15. Prepare and assist second serving residents to dining room for lunch.
16. Residents to early afternoon activities XE "Activity" .
17. Afternoon grooming/room check.
a. Clean clothing
b. Wash face and hands
c. Tidy room
18. Pass afternoon snacks.
19. Document XE "Documentation" status change/incidents per protocol.
20. Report off to next shift.
21. Med staff only.
3:00 pm - 11:30 pm
1. Verify resident status changes with previous shifts. Check documentation XE "Documentation" .
2. Rounds every 2 hours.
3. Incontinent care every 2 hours.
4. Housekeeping duties as assigned.
5. PRN XE "Medications:PRN" medications as needed (med aides only).
6. Set-up and pass 4:30 pm medications (med aides only).
7. First serving residents to dining room at 4:30 pm. Second serving residents to dining room at 5:30 pm.
8. Residents to pm activities XE "Activity" .
9. Set-up and pass 8:30 pm medications (med aides only).
10. Assist residents as needed with evening care.
a. Oral care
b. Dentures XE "Dentures" in labeled cup
c. Assist into night clothes
d. Toileting
e. Incontinent care
f. Remove soiled clothing and put in hamper
g. Remove assistive devices (hearing aids, etc.)
h. Safety check
i. Pathway clear to bathroom
j. Room a comfortable temperature XE "Vital Signs:Temperature"
k. Extra blankets, etc.
11. Check lighting XE "Lighting" .
12. Outside doors secured. (from outside only)
13. Document XE "Documentation" status change/incidents per protocol.
14. Report off to next shift.
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Sexual Expression |
The community respects the resident’s need for sexual expression and intimacy.
Procedure
1. Resident privacy is observed by scheduling for private time, knocking on doors before entering, etc.
2. Verify the resident’s ability to give consent by consulting with the resident’s physician XE "Physician" for residents interested in pursuing sexual relationships.
3. When a resident displays inappropriate sexual activity XE "Activity" / exposure, have staff remind the resident of the need for privacy and then move the resident to his or her room.
4. Discuss the resident’s sexual behavior with caregivers. Reinforce the idea that sexual behavior is normal and that acknowledging a resident’s sexuality is appropriate.
5. Educate families about resident rights related to sexuality and the normalcy of sexual expression.
6. When a resident interacts or touches staff inappropriately, the Administrator XE "Administrator" reinforces care techniques to avoid such problems. For example:
a. Identify yourself when ready to provide care.
b. Stand at the side, rather than in front of the residents reach when providing personal care.
c. Give the resident something to hold when providing personal care.
Assisted Living
Policy and Procedure Manual
Medication XE "Medications" Management
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POLICY: |
Medication Storage |
Medications XE "Medications" will be stored in a manner that ensures maintenance of both the integrity of the medication and the safety of all residents residing in the community.
Procedure
1. All medications XE "Medications" , including over-the-counter XE "Medications:Over-The-Counter" , are kept in locked storage at all times.
2. All medications XE "Medications" must be stored in accordance with label instructions (refrigerate, room temperature XE "Vital Signs:Temperature" , out of direct sunlight, etc.).
3. Medication XE "Medications" requiring refrigeration are stored in a separate, locked refrigerator that is used solely for medication storage.
4. If resident is allowed to keep his/her own medications XE "Medications" , the Administrator XE "Administrator" ensures:
a. Locked storage is maintained in the resident’s room to prevent access by other residents.
b. Physician XE "Physician" orders are on file in the resident’s chart indicating the resident is able to store and self-administer his/her medications XE "Medications" .
c. Quarterly evaluation of the resident’s ability to safety store and self-administer his/her medications XE "Medications" .
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Medication Records |
Records of medications XE "Medications" are maintained.
Procedure
1. A record of all medication XE "Medications" brought into the community is maintained for three years.
2. A record of medications XE "Medications" that are disposed of in the community is maintained for at least 3 years.
3. Written physician XE "Physician" orders for all medications XE "Medications" are maintained in the resident’s chart in the “Physician Orders” section.
4. Medication XE "Medications" Administration Record XE "Medications:Medication Administration Record" s (MARs) are maintained for all medications poured and/or passed by community staff.
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Telephone Orders |
Telephone orders for medications are not permitted. Prescribers will be asked to fax orders directly to the community.
Procedure
1. If a physician or other authorized prescriber attempts to give a telephone order, he/she is asked to fax the order to the community.
2. Community staff may write the order on the appropriate form and fax it to the prescriber for a signature.
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Medication Labels |
Community staff does not alter prescription labels.
Procedure
1. Community staff does not alter prescription labels. In order to maintain a label that matches the current physician XE "Physician" ’s order, the designated staff person XE "Administrator" :
a. Without obscuring the original label, flags the container with a brightly colored sticker and writes on it “order changed,” with the date, time, and his/her initials.
b. The designated staff person highlights the old order in the MAR XE "Medications:Medication Administration Record" and writes: “order changed,” with the date, time, and his/her initials.
c. The designated staff person transcribes the new order in the next available space in the resident’s MAR XE "Medications:Medication Administration Record" .
2. The designated staff person discusses the change with resident and/or responsible party XE "Family/Responsible Party" .
3. The designated staff person ensures the new medication XE "Medications" instructions are transmitted to the pharmacy so consecutive refills are appropriately labeled.
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Resident Arrives with a Medication |
When a resident arrives at the community with a new medication XE "Medications" , steps will be taken to ensure proper storage and handling of the medication. Physician XE "Physician" ’s orders will be verified for all medications.
Procedure
1. Each physician XE "Physician" is contacted to ensure that the physician is aware of all medications XE "Medications" currently taken by the resident.
2. Containers are inspected by a pharmacist to ensure the labeling is accurate.
3. The Administrator XE "Administrator" discusses medications XE "Medications" with the resident or the responsible party XE "Family/Responsible Party" .
4. If the physician and administrator XE "Administrator" agree that the resident is capable of self-storage and self-administration of medication XE "Medications" , the resident’s medications are stored in a locked compartment in his/her room.
5. The medications XE "Medications" are placed in the medication room in an appropriately labeled drawer, bin, etc., if central storage is required.
6. The medications XE "Medications" are appropriately listed on the MAR XE "Medications:Medication Administration Record" , verifying accuracy according to physician XE "Physician" orders.
7. All medications XE "Medications" not self stored or self administered by the resident are logged on to the Centrally Stored Medication Record.
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Medication Refills |
Medication XE "Medications" refills will be obtained in a timely manner to ensure residents have all physician XE "Physician" ordered medication available.
Procedure
1. The Designated staff person XE "Administrator" contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication XE "Medications" , unless medication is on a cycle refill with the pharmacy. When the medication is ordered it is entered onto the Refill Roster. When medications are received they are entered on the Refill Roster.
2. If necessary, the prescribing physician XE "Physician" is contacted for a new order.
3. Medications XE "Medications" are never allowed to run out unless directed to by the physician (obtain this direction in writing) XE "Physician" .
4. Containers are inspected to ensure all information on the label is correct.
5. Any changes in instructions and/or medication XE "Medications" are noted; for example, change in dosage, change to generic brand, etc.
6. Medications XE "Medications" are logged on the Centrally Stored Medication Record when received.
7. The Designated staff person XE "Administrator" discusses any changes in medications XE "Medications" with the resident, responsible party XE "Family/Responsible Party" and appropriate staff.
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Medications are Permanently Discontinued |
Permanently discontinued medication XE "Medications" will not be retained in the community.
Procedure
1. The Designated staff person XE "Administrator" confirms with physician XE "Physician" the order to permanently discontinue the use of the medication XE "Medications" , and obtains written documentation XE "Documentation" of the discontinuance from the physician, prior to destroying.
2. The Designated staff person XE "Administrator" discusses the discontinuance with the resident and/or responsible party XE "Family/Responsible Party" .
3. To properly dispose of permanently discontinued medications XE "Medications" the Designated staff person XE "Administrator" and another adult witness who is not a resident:
a. Returns the medication XE "Medications" to the dispensing pharmacy for disposal; or
b. Disposes of the medication XE "Medications" in a medical waste receptacle that is picked up at regular intervals by a licensed medical waste company.
4. Medications XE "Medications" to be returned to the pharmacy are held in a bin labeled “return to pharmacy” in the medication room until the time of pick-up by the pharmacy.
5. The Designated staff person XE "Administrator" and witness will document XE "Documentation" destruction on the Centrally Stored Medication XE "Medications" Record.
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Hold Orders |
Temporarily discontinued ("dc") and/or “HOLD” medications XE "Medications" will be held from use by the resident as instructed by the physician XE "Physician" .
Procedure
1. The Designated staff person XE "Administrator" discusses the change with the resident and/or responsible party XE "Family/Responsible Party" .
2. The Designated staff person XE "Administrator" obtains a written order from the physician XE "Physician" to HOLD the medication XE "Medications" .
3. Without obscuring the label, the medication XE "Medications" container is flagged with a brightly colored sticker where the Designated staff person XE "Administrator" writes: “HOLD,” the date, the time, and his/her initials.
4. The medication XE "Medications" is not given to the resident until the date and/or time indicated in the physician XE "Physician" ’s hold order.
5. The medication XE "Medications" is placed into a plastic bin labeled “On Hold Medications” in the medication room.
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Expired Medications |
Expired medication XE "Medications" will be not be given to any resident or responsible party XE "Family/Responsible Party" , nor retained in the community.
Procedure
1. Expired medications XE "Medications" are not used.
2. The Designated staff person XE "Administrator" inspect containers regularly for expiration dates.
3. The Designated staff person XE "Administrator" communicates with physician XE "Physician" and pharmacy promptly to obtain a refill.
4. To properly dispose of expired medications XE "Medications" the Designated staff person XE "Administrator" and another adult witness who is not a resident:
a. Returns the medication XE "Medications" to the dispensing pharmacy for disposal; or
b. Disposes of the medication XE "Medications" in a medical waste receptacle, which is picked up at regular intervals by a licensed medical waste company.
5. The Designated staff person XE "Administrator" and witness will document XE "Documentation" destruction on the Centrally Stored Medication XE "Medications" Record.
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Medications Left Behind by a Resident |
When a resident moves out of the community, all medications XE "Medications" , including over-the-counter XE "Medications:Over-The-Counter" s, should go with resident when possible.
Procedure
1. If the resident dies, prescription medications XE "Medications" are to be destroyed.
2. To properly dispose of medications XE "Medications" left behind by a resident, the Designated staff person XE "Administrator" and another adult witness who is not a resident:
a. Returns the medication XE "Medications" to the dispensing pharmacy for disposal; or
b. Disposes of the medication XE "Medications" in a medical waste receptacle, which is picked up at regular intervals by a licensed medical waste company.
3. The Designated staff person XE "Administrator" and witness will document XE "Documentation" destruction on the Centrally Stored Medication XE "Medications" Record.
4. Document XE "Documentation" on Centrally Stored Medication XE "Medications" Record when medication is transferred with the resident. Obtain signature of person accepting the medications (i.e., responsible party XE "Family/Responsible Party" ) will be obtained, indicating agreement with the quantity of each medication transferred out of the community.
5. Medication XE "Medications" records are retained for at least three years.
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POLICY: |
Medication Refusal and/or Missed Doses |
No resident will be forced to take any medication XE "Medications" . Steps will be taken to avoid missed or refused doses of medications and related adverse reactions.
Procedure
1. Missed/refused medications XE "Medications" are documented in the resident's medication record and the prescribing physician XE "Physician" notified immediately or according to physician parameters. Physician parameters must be retained in writing and kept on file.
2. Physician XE "Physician" instructions regarding missed dose are followed.
3. The Designated staff person XE "Administrator" re-appraises the resident and contacts the physician XE "Physician" and responsible party XE "Family/Responsible Party" if the resident is continually refusing a medication XE "Medications" (s). If unable to resolve continued refusal XE "Refusal" , the resident’s relocation from the community may be necessary.
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Crushing Medications |
Medications XE "Medications" will be crushed in accordance with physician XE "Physician" ’s orders and state regulations, without infringing on the resident’s personal right to refuse medications.
Procedure
1. The Designated staff person XE "Administrator" obtains a physician XE "Physician" ’s order prior to crushing a resident’s medications XE "Medications" .
2. The pharmacist is consulted to verify appropriate foods the medication XE "Medications" may be mixed with. This phone conversation is documented in the resident’s chart.
3. The physician XE "Physician" order and documentation XE "Documentation" of the telephone XE "Telephone" consult is maintained in the resident’s record XE "Community Care Licensing" .
4. When crushing medications XE "Medications" :
a. A pill-crushing device is used.
b. The completely crushed medication XE "Medications" is mixed with an appropriate soft food such as applesauce or pudding, not a liquid.
5. The resident is clearly informed that he/she is receiving medications.
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Transferring Medications for Home Visits and Outings |
Staff will assist resident to obtain/maintain necessary medications XE "Medications" for use while not in the community.
Procedure
1. When a resident leaves the community for a short period of time during which only one dose of medication XE "Medications" is needed, the Designated staff person XE "Administrator" gives the medications to a responsible party XE "Family/Responsible Party" in an envelope (or similar container) labeled with the resident's name, name of medication(s), and instructions for administering the dose.
2. If the resident is to be gone for more than one dosage period, the Designated staff person XE "Administrator" may:
a. Give the full prescription container to the resident, or responsible party XE "Family/Responsible Party" , or
b. Have the pharmacy fill a separate prescription or separate the existing prescription into two bottles, or
c. Have the resident's family XE "Family/Responsible Party" obtain a separate supply of the medication XE "Medications" for use when the resident visits the family. If family maintains a separate supply, the Designated staff person XE "Administrator" supplies them with current physician XE "Physician" orders prior to every outing or home visit.
4. The Designated staff person XE "Administrator" reviews the resident’s physician XE "Physician" orders, appraisal XE "Appraisals" and service plan XE "Service plan" to verify the ability of the resident to store and self-administer medications XE "Medications" while away from the community. If it is not safe to give the medications to the resident, the medications are entrusted to the person who is escorting the resident off the community premises.
5. The person entrusted with the medications XE "Medications" agrees in writing as to the amount of medication received on behalf of the resident and the appropriate dosing amount and schedule.
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POLICY: |
Sample Medications |
Sample medications XE "Medications" may be used when provided by the prescribing physician XE "Physician" . All safety controls imposed on other medications will apply to sample medications as well.
Procedure
1. The Designated staff person XE "Administrator" ensures that all sample medications XE "Medications" received into the community are provided by the prescribing physician XE "Physician" .
2. Sample medications XE "Medications" will be labeled with all the information required on any prescription label except pharmacy name and prescription number.
3. Sample medications XE "Medications" are centrally stored, documented and handled in the same manner as other prescription medications.
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POLICY: |
Use of Emergency Medications |
Residents who have a medical condition requiring the immediate availability of emergency medication XE "Medications" (i.e. nitroglycerine, inhaler, etc.) for life-saving purposes may maintain the medication in his/her possession if the safety the resident and other residents can be maintained and state regulatory requirements are followed.
Procedure
1. A physician XE "Physician" order is received stating that the resident is capable of determining the need for a dosage of the medication XE "Medications" and has determined that possession of the medication by the resident is safe.
2. This determination by the physician XE "Physician" is maintained in the individual's file and available for inspection by the state licensing agency.
3. The physician XE "Physician" 's determination clearly indicates the dosage and quantity of medication XE "Medications" that should be maintained by the resident.
4. Neither the community designated staff person XE "Administrator" nor state licensing agency staff has determined that the medications XE "Medications" must be centrally stored in the community due to risks to others or other specified reasons.
5. If the physician XE "Physician" has determined it is necessary for a resident to have medication XE "Medications" immediately available in an emergency but has also determined that possession of the medication by the resident is dangerous, then that resident may be inappropriately placed and may require a higher level of care.
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POLICY: |
Injections |
Injectable XE "Medications:Injectables" medications XE "Medications" will be administered by authorized licensed nurses or physicians, according to physician XE "Physician" ’s orders and state regulatory requirements.
Procedure
1. Injections XE "Medications:Injectables" are administered only by the resident themselves or by a licensed medical professional. Licensed medical professional includes Doctors of Medicine (MD XE "Physician" ), Registered Designated staff persons (RN), and Licensed Practical/Vocational Nurses (LPN/LVN).
2. Licensed medical professionals administer only medications XE "Medications" /insulin that they have drawn up, or have been predrawn by the pharmacy or the drug manufacturer.
3. If the resident administers his/her own injections XE "Medications:Injectables" , physician XE "Physician" verification of the resident's ability to do so is maintained in the resident’s record.
4. The Designated staff person XE "Administrator" ensures sufficient amounts of medications XE "Medications" , test equipment, syringes, needles, and other supplies are maintained in the community and stored properly.
5. Syringes and needles are disposed of in a "container for sharps," and the container shall is kept inaccessible to residents. The container shall be removed from the community by an appropriate medical waste company.
6. Insulin and other injectable XE "Medications:Injectables" medications XE "Medications" are kept in the original containers until the prescribed single dose is measured into a syringe for immediate injection.
7. Insulin or other injectable XE "Medications:Injectables" medications XE "Medications" may be packaged in pre-measured doses in individual syringes prepared by a pharmacist or the manufacturer.
8. Syringes may be pre-filled under the following circumstances:
a. Pre-filled syringes prepared by a registered nurse XE "Administrator" , may be self-injected by residents who are able and approved to self-inject.
b. The registered nurse (RN) must not set up insulin syringes for more than seven days in advance. The pre-drawn insulin is only for the resident to self-administer. An LVN may not pre-draw insulin.
9. Injectable XE "Medications:Injectables" medications XE "Medications" that require refrigeration must be kept inaccessible to residents.
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POLICY: |
Over-the-Counter (OTC) Medications |
A physician XE "Physician" order is required for all OTC XE "Medications:Over-The-Counter" medications XE "Medications" .
Procedure
1. OTC XE "Medications:Over-The-Counter" preparations are centrally stored, documented and handled in the same manner as prescription medications XE "Medications" .
2. The Designated staff person XE "Administrator" contacts the physician XE "Physician" for prescriptions for OTC XE "Medications:Over-The-Counter" preparations prior to their use.
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Psychotropic Medications |
Psychotropic medications XE "Medications" are given in a safe manner according to physician XE "Physician" orders. The community minimizes the use of psychotropic medications when possible.
Procedure
1. Behavioral and environmental interventions are attempted to avoid over or unnecessary use of psychotropic medications XE "Medications" .
2. Caregivers are educated on appropriate interventions for anxiety, agitation, dementia XE "Dementia" -related behavioral challenges, and potential adverse effects of psychotropic medications XE "Medications" .
3. The Designated staff person XE "Administrator" encourages caregivers to report adverse effects such as extrapyramidal symptoms XE "Extrapyramidal Symptoms" and tardive dyskinesia XE "Tardive Dyskinesia" .
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Warfarin and Other Anticoagulants |
Residents taking warfarin or other anticoagulants will receive assistance with necessary monitoring and/or lab tests.
Procedure
1. Residents receiving Coumadin XE "Medications:Coumadin (warfarin)" are instructed on signs and symptoms of complications, and to report these immediately to their physician XE "Physician" and to the Administrator XE "Administrator" .
2. Staff are trained on monitoring residents receiving warfarin (Coumadin XE "Medications:Coumadin (warfarin)" ) or other anticoagulants.
3. The Administrator XE "Administrator" makes arrangements for transportation to lab appointments as required.
4. Lab results are reported directly to the prescribing physician.
5. The Medication XE "Medications" Administration Record XE "Medications:Medication Administration Record" is updated immediately upon receiving the Coumadin XE "Medications:Coumadin (warfarin)" dosing change from the prescribing physician XE "Physician" .
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Narcotics, Controlled Substances, and Preventing Drug Diversion |
All medications are stored in a secure manner, as outlined in other policies. Special storage and security procedures will be followed to protect controlled substances (narcotics, etc) and to help prevent drug diversion.
Procedure
1. All medications XE "Medications" , including over-the-counter medications XE "Medications:Over-The-Counter" , are kept in locked storage at all times.
a. Only authorized staff members are given keys to the medication storage area.
b. Staff members do not take keys home or otherwise off community premises.
2. A Narcotic Count Sheet will be maintained for all narcotic medications.
a. When a narcotic is received in the community, it is counted by two staff members and added to the narcotic sheet with the current medication count reflected in the amount on hand.
b. Each time a resident receives assistance with self-administration of a narcotic, this is documented and the amount of medication on hand is updated on the Narcotic Count Sheet.
c. At the end of each shift, the staff member responsible for medication completing his/her shift, and the staff member responsible for medications who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches was it listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet confirm the accurate count of narcotics on hand.
d. Any discrepancies are immediately reported to the Administrator.
3. When medications are to be destroyed, the destruction must be witnessed by the staff member responsible for medications and a pharmacist. The destruction is documented, including the amount of medication destroyed and a signature from both witnesses.
4. Staff members will be trained to identify drug diversion and encouraged to report suspected drug diversion to the Administrator for proper investigation.
a. Any drug diversion will be reported to the state licensing agency, law enforcement, and any other agencies as required.
Assisted Living
Policy and Procedure Manual
Emergencies and Medical Needs
|
POLICY: |
Physician and Other Medical Appointments |
The resident will receive assistance in obtaining necessary medical care.
Procedure
1. Residents and responsible parties are informed to notify the Administrator XE "Administrator" of pending physician XE "Physician" or other medical appointments.
2. The scheduled physician XE "Physician" visits are entered on the physician appointment calendar.
3. The following accompanies the resident on all physician XE "Physician" visits:
a. Physician XE "Physician" Visit form.
b. Photocopy of current MAR XE "Medications:Medication Administration Record" (originals are never sent).
c. Any other requested documentation XE "Documentation" (daily glucose reading, etc.).
d. The Physician XE "Physician" Visit form is returned to the community and all orders transcribed by the licensed Administrator XE "Administrator" or supervisor on duty.
4. Family XE "Family/Responsible Party" /responsible party may transport XE "Transport" the resident to appointments. The Administrator XE "Administrator" instructs caregivers to have the resident appropriately dressed and ready for transport.
5. Should the resident not have transportation, the Administrator XE "Administrator" arranges for necessary transportation.
6. If a resident is unsafe to be left without an escort, the Administrator XE "Administrator" arranges for a staff member to accompany the resident.
7. Should the Administrator XE "Administrator" determine a resident is not stable, safe, or comfortable enough for van/car transportation, arrangements are made for ambulance transport XE "Transport" .
8. It will be disclosed to the resident/responsible party XE "Family/Responsible Party" upon admission XE "Admission" , that off-hour, unscheduled, or ambulance transportation is the financial responsibility of the resident.
|
POLICY: |
Labs and Outside Medical Services |
The resident will receive assistance with arrangements for outside medical services.
Procedure
1. Residents and responsible parties are informed to notify the Administrator XE "Administrator" of any pending outside medical services.
2. The scheduled service is calendared.
3. Should the resident not have transportation, the Administrator XE "Administrator" arranges for a staff member to accompany the resident.
4. If the resident is unable to be left without an escort, the Administrator XE "Administrator" arranges for a staff member to accompany the resident.
5. It is disclosed to the resident and responsible party XE "Family/Responsible Party" upon admission XE "Admission" , that off hour unscheduled or ambulance transportation is the financial responsibility of the resident.
6. The Administrator XE "Administrator" instructs all labs reporting or transmitting values to directly transmit to the physician XE "Physician" . Unlicensed XE "Unlicensed Staff" caregivers may not take verbal lab values.
|
POLICY: |
Licensure of Nursing Personnel |
Nursing personnel must present verification of such license XE "License" prior to or upon employment.
Procedure
1. At the time of employment, nursing personnel who require a license XE "License" or registration present verification of such license to the administrator XE "Administrator" .
2. A copy of the current license XE "License" and registration number is filed in the employee’s personnel record.
3. A copy of the annual renewal (as applicable) is presented to the administrator XE "Administrator" .
4. If the validity or standing of a license XE "License" is in question, the administrator XE "Administrator" will contact the appropriate board for verification.
5. Until the license XE "License" is verified, the nurse will not perform any duties requiring licensure.
|
POLICY: |
Medical Emergencies |
The resident will receive emergency medical care when needed to prevent further injury XE "Injury" or illness.
Procedure
1. Caregivers immediately summon the community Administrator XE "Administrator" should a resident exhibit signs and symptoms of a medical emergency.
2. The Administrator XE "Administrator" makes a determination as to the severity of the situation.
3. The community summons emergency medical services by calling 911 XE "911" ), when the resident exhibits signs and systems of distress and/or emergency condition. Examples include, but are not limited to:
a. New onset of chest pain XE "Pain" ;
b. Recurrent chest pain XE "Pain" , unrelieved in 15 minutes by previously ordered nitroglycerin XE "Medications:Nitroglycerin" given as ordered;
c. Unconsciousness;
d. Fall with deformity, severe pain XE "Pain" or head injury XE "Injury" ;
e. Uncontrolled bleeding XE "Bleeding" ;
f. First time seizure XE "Seizure" ;
g. Recurring seizure XE "Seizure" which last for more than 1 minute;
h. Sudden onset severe pain XE "Pain" ;
i. Shortness of breath;
j. Sudden lack of muscle control, ability to communicate, drooping facial expression or other signs of stroke XE "Stroke" ;
k. Low blood sugar (according to physician XE "Physician" order parameters, usually <60);
l. Excessively high blood sugar, according to physician XE "Physician" order parameters;
m. Poisoning;
n. Fever XE "Fever" which is not lowering despite interventions and fever reducing agents;
o. Choking;
p. Psychiatric XE "Psychiatric" crisis XE "Crisis" .
4. A non-emergency transport XE "Transport" is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding XE "Bleeding" , etc.
5. The Administrator XE "Administrator" contacts the family/responsible party XE "Family/Responsible Party" , as quickly as possible, once the resident is safely under the care of the paramedics XE "Paramedics" . Unless instructed otherwise by the family/responsible party, this includes anytime, 24-hours a day.
6. The Administrator XE "Administrator" or caregivers are not required to obtain permission from the family/responsible party XE "Family/Responsible Party" before summoning emergency medical services.
7. A staff member remains with the resident until paramedics XE "Paramedics" transport XE "Transport" out of the community.
8. A copy of the current MAR XE "Medications:Medication Administration Record" is given to the paramedics XE "Paramedics" , along with the Emergency Identification Form.
9. The actual medications XE "Medications" are retained in the community.
10. The staff person observing the transport XE "Transport" out of the community will note what belongings are going with the resident, such as jewelry, dentures XE "Dentures" , prosthetic devices, etc.
11. A narrative chart entry is made in the resident’s chart regarding the circumstances which led up to the call (Data), what care was provided by the staff, including any first aid (Action), as well as the resident’s response to the action (Response).
12. An Incident Report is completed.
|
POLICY: |
Psychiatric Emergencies |
Appropriate care will be arranged for should a resident be in psychiatric XE "Psychiatric" crisis XE "Crisis" .
Procedure
1. Caregivers immediately report to the Administrator XE "Administrator" any significant change in resident affect, personality, or behavior.
2. Any verbalization of suicidal ideation are taken seriously by caregivers and reported to the Administrator XE "Administrator" .
1. NOTE: Should an Administrator not be on duty, suicidal ideations would be reported to the immediate supervisor or medical professional XE "Administrator" .
2. Should a resident show evidence of violence (e.g. throwing objects, attempting to strike another resident, etc.) other residents are immediately removed from the area and assistance is summoned. Objects that could be used as a weapon are removed from the area.
3. Physical force is not used to subdue a resident.
4. If the severe behavior continues, call 911 XE "911" . Monitor the resident until assistance arrives.
5. An Incident Report is completed for all psychiatric XE "Psychiatric" crises and given to the administrator XE "Administrator" .
6. All psychiatric XE "Psychiatric" crises are reported to the resident’s responsible party XE "Family/Responsible Party" .
|
POLICY: |
Falls |
Should a resident experience a fall XE "Falls" , staff will provide or arrange for necessary emergency care, and will follow up with necessary service plan XE "Service plan" updates.
Procedure
1. Should the resident have trauma XE "Trauma" resulting in deformity, exhibit any change in level of consciousness XE "Consciousness" , received obvious head or significant trauma the Administrator XE "Administrator" or caregivers summon emergency medical services (call 911 XE "911" ).
2. When a resident falls XE "Falls" caregivers are instructed to summon immediate assistance from the Administrator XE "Administrator" or another caregiver.
3. Caregivers do not move the resident, except to protect against further injury XE "Injury" , as in the case of a dangerous environment.
4. The physician XE "Physician" is contacted for further instructions if the head was not involved in the fall XE "Falls" and the resident is able to move all extremities.
a. The Administrator XE "Administrator" instructs caregivers to provide appropriate care and frequent resident checks. Any change in status is reported to the Administrator.
5. An incident report is completed XE "Administrator" XE "Community Care Licensing" .
6. The Administrator XE "Administrator" informs the physician XE "Physician" of subsequent falls XE "Falls" and instability. Medical intervention, physical therapy, and/or gait analysis is arranged when residents remain a significant risk for falls.
7. Ongoing falls may require relocation from the community.
|
POLICY: |
Death of a Resident |
The community will take appropriate action in the event of the death XE "Death" of a resident.
Procedure
1. Call 911 XE "911" . Emergency Medical Services must be summoned to determine death XE "Death" , unless a hospice XE "Hospice" nurse XE "Administrator" is present at the bedside.
2. Do not move the body. The body may not be moved until there is either coroner XE "Coroner" release of the body or the police or sheriff on-site gives direct explicit permission to move the body. Staff should remain with the body at all times until paramedics XE "Paramedics" arrive.
3. Notify the resident’s primary physician XE "Physician" .
4. Notify the administrator XE "Administrator" .
5. The coroner XE "Coroner" must be contacted. Once paramedics XE "Paramedics" have pronounced the body (via communication with the physician XE "Physician" or coroner XE "Coroner" ), coroner release of the body must be obtained, allowing for transport XE "Transport" to the funeral home of the resident or family XE "Family/Responsible Party" ’s choice.
6. Notify the family XE "Family/Responsible Party" . Once the body has been pronounced the family XE "Family/Responsible Party" may be told of the death XE "Death" . Frequently the physician XE "Physician" will make this phone call. Otherwise, the administrator XE "Administrator" or the Administrator will notify the family.
7. Prepare the room for visitors XE "Visitors" if required. Occasionally family XE "Family/Responsible Party" or significant other will want to spend a few moments with the resident prior to transport XE "Transport" out of the community. In consideration, tidy the room, remove linens, etc., with objectionable odors and put a chair near the bed XE "Bed" . Lights XE "Lighting" should be turned on to a comfortable level. Insert the resident’s dentures XE "Dentures" (if applicable), close the resident’s mouth and eyes.
8. Contact the funeral home. Once coroner XE "Coroner" release has been obtained, the resident may be removed from the community. Call the funeral home designated. The resident should remain no longer than two hours in the community, if possible.
9. Document XE "Documentation" appropriately.
10. Submit a death XE "Death" report to the state licensing agency.
|
POLICY: |
Elopement/Missing Resident |
Elopement precautions and response procedures are carried out for resident safety.
Procedure
1. ELOPEMENT DRILLS
a. Elopement drills are conducted a minimum of twice per year and documented accordingly.
2. MISSING PERSON – GENERAL PROCEDURE
a. Local contact numbers of bus, rail, cab or other modes of transportation will be maintained for possible contact in emergency search.
b. Staff shall remain alert and follow re-direction techniques if a wandering resident gains access to any exit areas.
c. Staff shall request help if wandering resident cannot be redirected easily.
d. In house transportation staff will be notified of potential elopers possibly seeking rides and advised to be observant for wandering confused residents.
e. Staff will be routinely alerted by the Administrator of residents identified to be at risk
f. Service plans will reflect interventions for resident safety
g. Routine safety checks will be made by staff.
h. Flashlights and emergency first aid kits will be included in emergency supplies to accommodate searches outside
i. Walkie-talkie and cell phones are made available during outside searches
3. MISSING RESIDENT
a. Staff alerts immediate supervisor to begin a thorough search of entire community area. This includes searching bathroom areas, bedroom closets, under beds and window areas to ensure windows were not used as exit.
b. Administrator is immediately notified.
c. The Administrator or designee alerts other departments to ensure entire community is on alert.
d. A thorough re-search of building including stairwells, roofs, basements and outdoor area is expanded with ancillary staff and any volunteers.
e. Automobile searches by staff & volunteers are conducted in surrounding neighborhood.
f. All search staff call or report back to community regarding status within 15 minutes.
4. IF RESIDENT IS STILL MISSING
a. Notify sheriff /police department by calling 911 .
b. Provide local law enforcement with the following:
i. Resident full bodied photo
ii. Description of current clothing he/she was wearing
iii. Any other physically identifying information
iv. Information in regard to current medication/treatment needs
v. Information in regard to resident’s nickname or typical behavior
c. Notify the resident's responsible party.
d. Continue search efforts per direction of law enforcement.
5. MISSING PERSON – IF RESIDENT IS FOUND
a. Notify all searching parties.
b. Conduct assessment to identify possible injuries.
c. Transfer to hospital for further medical evaluation.
d. Notify physician.
e. Notify the resident's responsible party.
f. Complete an incident report and notify licensing agency per licensing requirement.
6. MISSING PERSON – WHEN RESIDENT RETURNS TO COMMUNITY
a. Obtain updated medical evaluation from hospital or doctors office. Initiate any new orders.
b. Establish private duty care for resident oversight until resident re-assessment indicates there is no longer a need.
c. Maintain resident behavior monitoring for identification of any triggers.
d. Complete resident record documentation.
e. Update service plan and resident summary to reflect potential elopement.
f. Inservice care staff and any relevant staff members.
g. Evaluate the community’s continued ability to meet the resident’s needs
i. Responsible party will be kept informed and assisted with alternative placement if determined to be necessary.
|
POLICY: |
Advance Directives |
Residents may have Advance Directives and/or Do-Not-Resuscitate (DNR) orders. The community staff will take steps to ensure, as best as possible, that a resident's wishes are honored.
Procedure
1. A Do-Not-Resuscitate order does not direct health professionals working in the community or any staff member to withhold all emergency care. The resident should receive all medications XE "Medications" , treatments and any other care as ordered by the physician XE "Physician" , as well as all emergency first aid care as necessary. Any necessary transfer to a higher level of care (acute hospitalization) should take place as necessary.
2. This policy shall at all times be available for review by the licensing agency and its representatives.
3. A resident requesting a Do-Not Resuscitate order be implemented will be directed to obtain the directive from their visiting home health nurse or physician XE "Physician" . No agent or employee of the community shall sign, witness or be legally recognized as a surrogate decision maker for the resident’s Do-Not-Resuscitate order.
4. A copy of the Do-Not-Resuscitate order will be placed in the resident’s file and in their room. Note: this is confidential information and must not be posted in a conspicuous place for visitors XE "Visitors" or other residents to see.
5. A list of all residents with a current valid Do-Not-Resuscitate order will be available in the following locations:
a. __________________________________________________________
b. __________________________________________________________
c. __________________________________________________________
6. Should a resident desire, a medic-alert XE "Alert" bracelet with a DNR medallion may be ordered and worn by the resident with a current Do-Not-Resuscitate status.
7. In the event of a crisis XE "Crisis" , emergency medical services should be immediately summoned for the resident. When the emergency medical service personnel arrive they should immediately be presented with the resident’s Do-Not-Resuscitate order.
Assisted Living
Policy and Procedure Manual
Documentation XE "Documentation" and Forms
|
POLICY: |
Confidentiality |
All resident data and information is treated as confidential.
Procedure
1. Resident charts, information, preadmission documentation XE "Documentation" , etc., are kept inaccessible to visitors XE "Visitors" and individuals not involved in the direct care and admission XE "Admission" of the resident.
2. Care and administrative staff given access to resident related documentation XE "Documentation" are trained during orientation to maintain confidentiality.
3. Photocopying and removal of resident information is strictly prohibited unless approved by the administrator XE "Administrator" .
4. Release of resident health and personal information is made:
a. When requested by the competent resident.
b. When requested by the resident’s conservator as allowed according to law.
c. After consent for release of information is signed by either party above.
5. State regulatory personnel as allowed under regulation may review resident information.
6. The ombudsman is provided the name of the resident, name and address of the responsible party XE "Family/Responsible Party" and room number of each resident upon request.
7. Medication XE "Medications" and other clinical information are provided only upon release by the resident or conservator, as appropriate.
|
POLICY: |
Narrative Charting Entries |
Narrative charting XE "Documentation:Charting" will be maintained to promote clear communication regarding resident care.
Procedure
1. The format for narrative charting XE "Documentation:Charting" is:
a. D = Data Enter all essential facts related to resident status.
b. A = Action State the actions/interventions made in response to the data.
c. R = Response Follow up and document XE "Documentation" the resident’s response to the action taken.
2. A narrative entry is made upon admission XE "Admission" , noting the date and time of admission, and any pertinent data regarding the resident’s response to their placement.
3. A narrative entry addressing current resident status is made every shift (or more often if necessary) for 48 hours after a fall XE "Falls" or sentinel event.
4. Except as stated in (2) and (3) above, staff utilize the charting XE "Documentation:Charting" by exception XE "Exception" related to resident status.
5. The Administrator XE "Administrator" reviews the narrative charting XE "Documentation:Charting" from the previous shift, for at risk residents.
|
POLICY: |
Incident Reports |
Injury XE "Injury" and unusual incidents will be reported in compliance with state regulatory requirements.
Procedure
1. The Unusual Incident form is used to document XE "Documentation" and report any incident which is a threat to a resident’s health, safety, welfare, or rights. This includes, but is not limited too occurrences such as:
a. Falls XE "Falls" .
b. Injury XE "Injury" .
c. Psychiatric XE "Psychiatric" crisis XE "Crisis" .
d. Unexplained absence.
e. Any violation of resident rights.
f. Any incident that threatens the health, welfare, or safety of the resident.
2. Any incident which is a threat to a resident’s health, safety, welfare, or right will be reported to the state licensing agency within 7 days of the incident and a report made via telephone XE "Telephone" within 24 hours of the incident.
3. The Administrator XE "Administrator" completes incident reports.
4. Incidents are reported to the resident's responsible party XE "Family/Responsible Party" . Document XE "Documentation" the date and time the report was made to the family/responsible party in the narrative charting XE "Documentation:Charting" section.
5. All incidents related to physical abuse, neglect, sexual assault, or exploitation are reported to the ombudsman, state licensing agency, and in the case of assault (physical or sexual) to law enforcement.
|
POLICY: |
Abbreviations |
Standardization of terms, definitions, abbreviations, acronyms, and symbols will be used to promote clear communication and accuracy of information.
Procedure
1. A standardized list of acceptable terms, abbreviations and acronyms is posted in each community charting XE "Documentation:Charting" area.
2. All staff are instructed to use only approved terms, abbreviations, and acronyms on this list for all charting XE "Documentation:Charting" .
3. Changes or additions to the list of acceptable terms are made after approval from the Administrator and administrator XE "Administrator" .
|
POLICY: |
Approved Abbreviations |
ALWAYS follow community policies regarding the use of abbreviations. Never “invent” a new abbreviation.
Remember, it is best to write words out and avoid the use of abbreviations. Medical professionals working with assisted living communities should be encouraged to avoid the use of abbreviations. Never guess at the meaning of an abbreviation; verify the meaning with the author.
|
A |
|
|
a |
Before |
|
ABD |
Abdomen |
|
AC |
Before eating |
|
AD |
Right dear |
|
ad lib |
As desired |
|
ADL |
Activity of daily living |
|
am |
Morning |
|
amb |
Ambulate |
|
AS |
Left ear |
|
ASAP |
As soon as possible |
|
AU |
Both ears |
|
B |
|
|
BID |
Twice a day |
|
BKA |
Below the knee amputation |
|
BM |
Bowel movement |
|
BP or B/P |
Blood pressure |
|
BPM |
Beats per minute |
|
BS |
Bowel or breath sounds |
|
C |
|
|
c |
With |
|
C |
Celsius or centigrade |
|
C&S |
Culture and sensitivity |
|
CA |
Cancer |
|
Ca |
Calcium |
|
CAD |
Coronary artery disease |
|
CAP |
Capsule |
|
CAT |
Computerized axial tomography, as in "CAT scan" |
|
CBC |
Complete blood count |
|
CBG |
Capillary blood gas |
|
CCU |
Clean catch urine |
|
CHF |
Congestive heart failure |
|
CNA |
Certified nurses aide |
|
CNS |
Central nervous system |
|
C/O |
Complaining of |
|
COPD |
Chronic obstructive pulmonary disease |
|
CPAP |
Continuous positive airway pressure, as in "CPAP machine" |
|
CPR |
Cardiopulmonary resuscitation |
|
CSF |
Cerebrospinal fluid |
|
CT |
Computerized tomography, as in "CT scan" |
|
CVA |
Cerebrovascular accident, aka "stroke" |
|
CXR |
Chest X-ray |
|
D |
|
|
DAT |
Diet as tolerated |
|
DC |
Discontinue or discharge |
|
DM |
Diabetes mellitus |
|
DNR |
Do not resuscitate |
|
DME |
Durable medical equipment |
|
DOB |
Date of birth |
|
DPT |
Diphtheria, pertussis, tetanus |
|
DVT |
Deep venous thrombosis or deep vein thrombosis |
|
DX or Dx |
Diagnosis |
|
E |
|
|
ECG |
Electrocardiogram |
|
ECT |
Electroconvulsive therapy |
|
ED |
Executive director |
|
EMS |
Emergency medical services |
|
ENT |
Ears, nose, and throat |
|
ETOH |
Ethanol, often used in reference to alcohol use/abuse |
|
F |
|
|
F |
Fahrenheit |
|
FBS |
Fasting blood sugar |
|
Fe |
Iron |
|
FTT |
Failure to thrive |
|
FU |
Follow-up |
|
FWB |
Full weight bearing |
|
FWW |
Front wheeled walker |
|
Fx |
Fracture |
|
G |
|
|
GI |
Gastrointestinal |
|
gr |
Grain, 1 grain = 65 mg |
|
gm |
Gram |
|
gt or gtt |
Drops |
|
GU |
Genitourinary |
|
H |
|
|
H |
Hour |
|
H2O |
Water |
|
HA |
Headache |
|
HDL |
High density lipoprotein |
|
Hgb |
Hemoglobin |
|
HO |
History of |
|
HOB |
Head of bead |
|
HOH |
Hard of hearing |
|
HR |
Heart rate |
|
HS |
At bedtime |
|
HTN |
Hypertension |
|
Hx |
History |
|
I |
|
|
I&O |
Intake and output |
|
ID |
Identification |
|
IDDM |
Insulin dependent diabetes mellitus |
|
IM |
Intramuscular |
|
INR |
International Normalized Ratio |
|
IPPB |
Intermittent positive pressure breathing |
|
IV |
Intravenous |
|
L |
|
|
L |
Left or Liter |
|
LOC |
Loss of consciousness or level of consciousness |
|
LPN |
Licensed practical nurse |
|
LVN |
Licensed vocational nurse, this term is used only in California and Texas |
|
M |
|
|
mL |
Milliliter |
|
MRI |
Magnetic resonance imaging |
|
MRSA |
Methicillin resistant staph aureus |
|
MS |
Multiple sclerosis |
|
N |
|
|
Na |
Sodium |
|
NAS |
No added salt |
|
NG |
Nasogastric |
|
NKA |
No known allergies |
|
NKDA |
No known drug allergies |
|
noc |
Nighttime |
|
NPO |
Nothing by mouth |
|
NS |
Normal saline |
|
NSAID |
Non-steroidal anti-inflammatory drugs |
|
NT |
Nasotracheal |
|
N/V |
Nausea and vomiting |
|
NVD |
Nausea, vomiting, and diarrhea |
|
O |
|
|
OD |
Right eye |
|
OOB |
Out of bed |
|
OS |
Left eye |
|
OTC |
Over-the-counter |
|
OU |
Both eyes |
|
oz |
Ounce |
|
P |
|
|
p |
After |
|
PC |
After meals |
|
PDR |
Physicians' desk reference |
|
pm |
Afternoon |
|
PO |
By mouth |
|
PRN |
As needed |
|
PT |
Physical therapy or Prothrombin time |
|
Q |
|
|
Q |
Every (e.g., Q6H = every 6 hours) |
|
QD |
Every day |
|
QH |
Every hour |
|
Q4h, Q6H, etc... |
Every 4 hours, every 6 hours, etc... |
|
QID |
Four times a day |
|
QNS |
Quantity not sufficient |
|
QOD |
Every other day |
|
R |
|
|
R |
Right |
|
RBC |
Red blood cell |
|
RDA |
Recommended daily allowance |
|
R/O |
Rule out |
|
ROM |
Range of motion |
|
RT |
Respiratory therapy |
|
Rx |
Treatment |
|
S |
|
|
s |
Without |
|
SL |
Sublingual |
|
SNF |
Skilled nursing facility |
|
S/O |
Significant other |
|
SOB |
Shortness of breath |
|
STAT |
Immediately |
|
Subq or SQ |
Subcutaneous |
|
Sx |
Symptoms |
|
T |
|
|
TB |
Tuberculosis |
|
Temp |
Temperature |
|
TIA |
Transient ischemic attack |
|
TID |
Three times a day |
|
TO |
Telephone order |
|
Tx |
Treatment |
|
U |
|
|
UA |
Urinalysis |
|
URI |
Upper respiratory infection |
|
US |
Ultrasound |
|
UTI |
Urinary tract infection |
|
V W X Y Z |
|
|
VO |
Verbal order |
|
VRE |
Vancomycin-resistant enterococcus |
|
WBC |
White blood cell or count |
|
W/C |
Wheelchair |
|
WNL |
Within normal limits |
|
YO |
Years old |
|
YTD |
Year to date |
|
Misc |
|
|
> |
Greater than |
|
< |
Less than |
|
= |
Equals |
|
# |
Number, pounds |
|
" |
Inch or second |
Care and Compliance Group, Inc. page 2
