This is the seventh in our series of posts about interactions with various departments of a long-term care facility.
Most large nursing facilities have a culinary department which includes a Registered Dietician, but state regulations vary as to specific staffing requirements. Assisted and foster care facilities may use the services of dieticians who are not on site. Culinary staff always seek input from residents and families through committees, surveys, and suggestion boxes. Individual requests in nursing facilities should be directed through aide or nursing staff and honored so that residents can obtain the nutrition needed for recovery and good health. It is most effective to share questions and complaints about food to the director of food services. Families and residents should be very specific about suggestions to help the culinary team develop food options that are more pleasing to the residents. They can also be discussed at care conferences with the representative of the culinary department.
There is some consensus in long-term care settings that complaints about food relate more to boredom and lack of control than to the actual quality of the food. In addition, the deterioration of taste buds, effect of medications on appetite, and general malaise of some residents makes food seem unappealing that would be acceptable in another setting. Families and residents should be aware that a staff person listening to a concern about the food being too bland, may have just been told by someone else that it is too spicy. The suggestion box will indicate that one person thought a specific meal was wonderful while another found the same meal inedible. Culinary staff in most facilities will continue to attempt to please as many residents as possible.
This is the sixth in our series of posts about interactions with various departments of a long-term care facility.
Activities and Recreation
Staff who provide or direct the activities in any long term facility fill a vital role. Residents in nursing facilities do not require nursing care for more than a few hours each day and usually cannot tolerate rehabilitative therapy for more than two hours. This leaves time to fill when families and friends can visit, but meaningful activities and pastimes that link residents back to their community can help to motivate them toward recovery or comfort them if recovery is not expected. In assisted care and foster homes, activities are even more critical as residents may have more energy and certainly have more time.
Activity staff may or may not have college educations or degrees but most should have an activity certificate for about 36 hours of training. Activity staff value any input from residents and families about interests, abilities, previous experiences and activities and personality styles. They are not able to provide any information about medical or care issues but can pass on concerns to administrative staff. They cannot provide care but do sometimes assist with transfers and positioning.
Someone in the activity department works every day in larger facilities and some event should be available for about ten or twelve hours daily. Families should advocate for age-appropriate activities that vary from group events and outings to one-on-one visits. Age-appropriate activities acknowledge that the person who went out last week for Thai food after seeing a newly released R-rated film will soon tire of a diet of pot roast and World War II musicals. Many facilities use volunteers to enhance staffing and events. Performing and education individuals and groups are also seen in many facilities.
Addendum: Actvities at Cedar Sinai Park
Activities at Cedar Sinai Park are coordinated by the recently-renamed Life Enrichment Department. The name change came in recognition of the fact that in addition to activities, staff cover every non-medical aspect of resident life: shopping, visits, games, computer help, celebrations of life, voting, etc.
This is the fifth in our series of posts about interactions with various departments of a long-term care facility.
Skilled nursing and most intermediate facilities employ or contract for the services of skilled rehabilitation staff. These positions include:
physical and occupational therapists at bachelor’s or master’s level
physical and occupational therapy assistants at an associate’s or bachelor’s level
speech and language pathologists, informally known as speech therapists, who have master’s degrees
These services must be ordered by a physician or arranged for and paid privately by families. Unless paid privately, they are reimbursed by the resident’s insurance. If the resident has insurance from a health maintenance organization, that company approves establishment and continuation of rehabilitation services. If the resident has Medicare insurance with or without a supplemental policy, the rehabilitation staff determine if the services are covered by Medicare guidelines and the facility assumes the risk that, if they are audited, Medicare will agree to the reimbursement. Families and residents may appeal these decisions but if the appeal fails, the families and residents are liable to pay privately for the services.
Families are encouraged to observe the rehabilitation staff working with the resident to learn how to safely transfer and assist the resident. It is important to avoid spending the limited time allotted for these services in conversation unrelated to the rehabilitative portion of the care plan. The rehabilitative staff have no control over the Medicare guidelines or the insurance case management staff. They appreciate learning anything relevant about the resident’s prior function which was not available in the history and physical sent to the facility with the admission orders. This is best offered in writing for their ongoing use. Rehabilitative staff are also available at care conferences for further discussion.
Some family members may be distressed if their loved one appears to be making little progress in rehabilitation. The rehabilitative staff are responsible for guiding the process safely, and competent staff are able to motivate residents to exert themselves more than they would if simply offered opportunities to participate in therapy. However, staff cannot force residents to participate, nor can they work with those who are sleeping, unresponsive, or in too much pain or discomfort to benefit from therapies. It is an unfortunate fact of the reimbursement system that residents who may need some time to recover from their illness or injury will lose the opportunity to have rehabilitative therapy reimbursed. Some residents pay privately for custodial care until they can participate in covered therapy at a later time.
This is the fourth in our series of posts about interactions with various departments of a long-term care facility.
Licensed nurses direct the care plans in nursing facilities and oversee medications and care plans in most assisted facilities. Licensed nurses may be registered nurses–RN or licensed practical nurses–LPN. Licensed practical nurses typically have one year of education and are limited in providing some areas of care. Registered nurses have two years of education, a four-year bachelor’s degree, or a master’s degree. Although doctorates are available to nurses they are usually limited to positions at research and teaching institutions.
Certified nursing aides, or CNA’s, are the majority of staff in nursing facilities and provide most of the care. Requirements for education differ by state but tend to be in the range of 6-8 weeks of training with continued in-service training required. Certified nursing aides can enrich their credential with about two weeks of additional training in medication administration to become CMA’s, or certified medication aides. These aides work under the direct supervision of nursing staff. While they can respond to requests for assistance in providing transfers, re-positioning, food, cleaning, grooming and personal care, they cannot administer medication that has not been cleared as part of the care plan and if they are not CMA’s. They can, however, bring concerns to the nurse.
Responsible facilities will attempt to provide as much continuity of care as possible, allowing the same aides to work with a resident. This builds confidence, trust, and comfortable relationships that assist residents in recovery and adjustment to facilities. It also provides families with familiar faces and confidence in the treatment team. However, in many facilities there is high turnover in aide staff related to low pay, limited benefits, the field attracting young people in transition. This may force some facilities to use temporary staff from agencies, limiting the continuity of care.
Families may discover that some aides in facilities have been there for some time and are likely to remain there; family members can then focus relationships and communication on those staff to address care needs. Turnover is also more limited in rural areas due to personal decisions to limit commuting time or to remain in the area, or due to the lack of other opportunities for employment. In lower levels of care, aides who may or may not be certified provide assistance to residents as needed and are usually trained on the job. In most states, foster care providers must complete a certain number of hours of training prior to working in a facility and must continue their education annually with specified hours and subjects. Turnover in lower levels of care tends to be equally high for the same reasons as above.
This is the third in our series of posts about interactions with various departments of a long-term care facility.
Every resident in a licensed long-term care facility must have a primary care provider who is able to write medical orders. This is often the long-time physician for the resident and the relationship may have been established prior to admission. At other times, the medical director of the facility takes over the care of the resident. In skilled and intermediate nursing facilities a resident cannot receive even a vitamin or an antacid without the written order of the physician of record. Some facilities allow a physician to order self-administration of some medications. The usual pattern of interaction is for a charge nurse in a facility to recognize a need and call the physician with the appropriate medical information. The physician will then order medication, treatment, transfer to hospital or another level of care, or take no action at that time.
When a situation warrants a call to the physician, the family is also usually notified. The family may even have brought the issue to the nurse’s attention. There may be lapses of time while waiting for the physician’s response. This is frustrating for the nurse and other staff as well as for the family. Physicians have many demands on their time and attention and cannot respond to all requests at one time. In addition, some medical offices operate more according to their traditions than to maximize efficiency. However, if a pattern of delay is apparent and the facility appears to be making requests in an appropriate and timely manner, the resident or family would do well to be proactive and discuss
the issue with the physician. In extreme cases where a delayed or absent response endangers resident care, the facility will have a protocol to provide appropriate medical care.
This is a second in our series of posts about interactions with various departments of a long-term care facility.
Except for foster homes, most facilities have some kind of reception desk or area with a person answering
the phone. This is the first person anyone will meet at every visit or phone call. It is very unlikely
that the individual at the phone or desk will have any medical or other information about your family
member that can be shared without input from a nurse or administrative staff. The desk at most
facilities is a very busy place with many demands upon the receptionist. New requirements for added
security to limit access to facilities and residents to staff, families, and invited friends have added new
responsibilities to that position. Inquiries and interactions to the receptionist are best kept brief and