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
The term “providers” is a general title for all of the staff involved in direct care in a long-term care facility. Several reasons exist for encountering providers and various ways to make the encounter a positive and care-enhancing experience. We’ll run down the list of all of the staff categories, from administration to social services, at a long-term care facility.
Every facility has at least one administrator identified as the supervisor of the facility. Most have some
licensing status, such as nursing home administrator and assisted living administrator. These licenses
require classroom hours and testing and must be renewed periodically. Administrators would generally
like to meet every resident and family and are the people to address at any time with any issue if
other avenues have not been successful.
Administrators usually make the final decision whether a resident is admitted to the facility. They
look at the information from the hospital chart, at their own staffing availability, and at the acuity of
their residents. The latter term describes the amount of care that the current resident census requires.
A facility may have unoccupied beds but if the residents in the occupied beds require an unusually high level of care, the administrator may choose to keep an empty bed rather than admit another resident
with high care needs. Administrators in nursing facilities make these decisions in collaboration
with admissions staff, often located in social services. In assisted or residential care facilities, and in
foster homes, admission decisions are usually made by one person.
If the resident is receiving specialized rehabilitative treatment, such as physical therapy, other disciplines should seek to support a positive outcome from that treatment.
Nursing will attempt to stabilize the resident medically and provide effective pain control in order to maximize rehabilitative efforts that require focus and energy. Dietary staff will focus on sufficient nutrition to promote healing, skin health, and energy for rehabilitation. Activities or recreation staff will introduce diversions for promoting focus, socialization, gentle use of all muscle groups, skill building and relaxation, all of which will maximize the quality of the time spent in rehabilitation. Social services staff will follow up with the discharge plan that will reflect goals met and challenges to overcome in order to move to a lower level of care. The latter are not necessarily for the residents and families to address. Challenges may include staff tasks, such as equipment to purchase and home health services to arrange.
A resident who is expected to remain at the current level of care for a time will receive the same attention to care planning but without the time pressures for change to a lower level of care. Instead, the focus will be on positive adjustment to the facility with meaningful relationships and activities developed to match the resident’s personality, history, and expectations.
Care conferences are usually arranged within a week or two of a skilled-nursing admission and within the first month of a longer-term admission. The first conference is likely to last about 30 minutes. Regular quarterly conferences are held for long-term residents and these can last from 15 to 30 minutes. Quarterly conferences are usually held on a schedule and families and residents receive formal notice.
After a period of adjustment, some families stop attending care conferences, perhaps content that staff will provide the expected care. This is not necessarily a signal that families do not care, since most do visit and provide for needs as requested. However, the care conference is a special opportunity for some staff to interact more directly than usual with families. It can be disappointing to consistently report only to other staff and for the record with no input from families to enrich the care plan.
In a long-term care setting, we usually consider decisions related to medical care. There is consistency in the process and the resident gets every opportunity to make the decisions. The resident may have physical challenges to overcome or learn to tolerate, but unless otherwise demonstrated, staff in a facility assume the resident will direct her own care.
Most residents admit to long term care from a hospital setting, following an acute event, or at the end of a progressive illness. Any scenario presumes the need for a higher level of care than total independence at home. Documents from medical settings and providers describe the resident’s medical status and usually include some indication of mental capacity for decision-making. In some situations, the resident, then a patient in a hospital bed, was not responsive and family members were allowed and even required to make decisions. This status will usually be reviewed at each change in the level of care.
If the resident is incompetent, unable to communicate, unresponsive, or refuses to direct her own care, one family member will be asked to do so. This may already be clear at admission since someone, usually a family member, arranged for the admission, toured the facility, and so on. In some instances, tasks are divided among family members and the person arranging the care will not continue to make decisions after admission. This is especially true in the event of a family member visiting from another community.
Long-distance caregiving is a special challenge within any family and difficult for the facility to address. An adult child living in a different community may want very much to help and to be involve. She may feel very guilty about her perception of not sharing the burden of care with her parent or another sibling. These feelings may result in very energetic decision-making which may not be compatible with the culture of caregiving and decision-making that has evolved locally. The local caregiver may feel resentful which can lead to conflict and exhaustion. Besides staying in regular contact, long-distance caregivers should accept discrete, ongoing tasks which can be performed from afar, complete them as promised, acknowledge the devotion of the local family, and make some sacrifices to visit often and provide some respite.
Some residents and families are reluctant to make any decisions when an acute event has occurred. Their expectation is that medical staff, from the doctor in the hospital to the nurse in the long term care facility, will tell them what to do. There was a time in the history of medical care when this was the predominant pattern, but this is no longer the case. For both legal and ethical reasons, medical providers require full disclosure to patients and families and full involvement from them in the decision-making process. Providers will offer information about available treatment options and even make recommendations but they will require some input from the patient and family as to their preferences and understanding of risks and benefits.