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Posts from the ‘hospice’ Category

Oct 31

2 Comments

Father and Son

Goal Accomplished!

Since our first day of clinicals, we were taught about setting goals.  What is it that we want for the patient?  Do we want him to be free from injuries related to falls?  Maybe getting his A1C below 7 or his blood pressure to be below 150/90 is a desirable goal for a patient?  What about lab work and medications?  Does it make sense to set a goal concerning medication compliance or a serum potassium between 3.8 and 4.5 if a patient takes diuretics?

All of those goals meet the criteria we were taught as young nurses.  They are measurable, obtainable, and realistic.  They could all be achieved inside of an episode or throughout the episode, etc.  They would meet with approval from a surveyor.

The picture above is my friend, Bill and his dad.  At first glance it may seem like a picture of a patient with a caring family member.  It is so much more than that.

The gentleman to the right was Bill’s father long before he was a patient.  He is retired from the military.  He has had a long life filled with stories of success and failure, love and loss, happiness and sadness just like the rest of us.  I don’t think it would surprise him to find out that he is approaching the end of his life.  And that man – not the patient – could probably give a flying flip about his A1c or serum potassium level.

If you were to ask him what his goals were upon admission, he might tell you that he wants to spend more time with Bill.  Or if he is in pain, he would like some relief from the pain that causes him to be emotionally unavailable for visits with his loved ones.  He might have a goal of going to a relative’s wedding or just going to the store soon.  He may even have the unreasonable goal of running a marathon soon.

If you begin your relationship with your patient by finding out what they hope they to obtain by being your patient, you will be given the most powerful tool you can have in accomplishing the more traditional nursing goals.  Regardless of whether or not the goals are reasonable is really not our business.  We start where the patient is and we don’t mainline reality into him like a lethal injection.  If he wants to spend more time with less pain so he can visit his son, then we can use that to encourage him to participate in therapy.  If he wants to run a marathon, ask him what that would be like.   It could be that he has not had the time to mourn the loss of his younger self and your patience and willingness to listen will help him come to the conclusion that there may be a better way to live that doesn’t include running a marathon.

I am the very same person who swam on the swim team when I was four and the same teen aged girl who has been lost in more continents that most people travel to in a lifetime.  I am the one who married a man I later divorced.  That was me showing up at nursing school on the first day in a white skirt with coffee spilled all over it.

Maybe if you think back when you were 5 or 14 or 22, you will realize that it was you all along.

I cannot think of a better way to care for a patient with respect and dignity than by finding out who they have been all along and work with them to accomplish their goals. They are grown-ups just like us.  We get to determine what is best for us just as the men and women who honor us with the privilege of taking care of them.

And so on…..

 

Jun 30

2 Comments

Managing Medications

I know that there are a million things that can go wrong with a patient in the home but for some reason, I am stuck on medications this week.  For one thing, we have some control over the medication error variables.  And I do see a lot of ways that nurses can prevent errors.

One of my clients had this brilliant idea of calling LSU and asking for a pharmacist to sit in on weekly case conferences.  As a result, they now have fifth year students sitting in on case conferences to review medications with the nurses.  It doesn’t cost the agency a thing and I think it will be a great experience for the pharmacists to see first hand the plethora of medications patients take in the home environment.

Another tool that I have been using is a free iPad/iPhone program from Medscape.   Without having to spell all the meds, I can enter in a patient’s med profile in a matter of a minute and check for interactions and precautions.  There are two download options available.  Because I do not have a 4G iPad, I downloaded the database and it works for me even when there is no wireless.  I regularly get notices to update the database so it apparently is kept current.

As nurses, we pretty much know everything there is to know about a drug before we swallow a pill.  We should hold ourselves to the same level of certainty when it comes to medicating patients.  In the worst case scenario, if you have no iPad, iPhone, old fashioned drug book, it is a law that the pharmacy’s phone number be placed on any prescription bottle.  Call them!

Another resource I review almost daily is emailed FDA Medwatch alerts.  You can click on the link.  My personal suggestion is to limit your alerts to drugs and medical equipment because otherwise you will be flooded with emails.  I made a separate folder for the FDA.  Last week I learned that some pills labeled as hydrocodone didn’t actually have hydrocodone in them and another batch of hydrocodone with acetaminophen had more acetaminophen than the label said.   I get anywhere from two to ten alerts each week.  I think it is good information.

While all of these resources are good, it occurs to me that the biggest problem I see when reviewing clinical records is an apparent lack of concern regarding medications.  I don’t fully understand it.  I think there are still nurses who think if a doctor prescribes a medication, he must know what he or she is doing.  That is expecting too much of physicians who have patients with multiple doctors and pharmacies.  Often it is the home health care nurse, in the home with all of the medications who has the only true picture of what the patient is taking.  When you start expecting even your best doctors to be perfect, think back to the last time you made an error judgment or took a short cut that resulted in an undesirable outcome.

I know for me that was this morning.   And I like having people around who cover my back.  Remember that the quality of nursing starts in the field.  And it is much easier to improve the quality of nursing in the field if the agency has a culture that promotes excellence.  So whether you are in the field or behind a desk, get serious about medication errors.

Your comments are welcome below as are your emails.

Jun 27

13 Comments

May I Have Your Attention, Please?

I’ll be brief here. I am very, very busy and really don’t have time to blog today but I have a message and an insatiable desire to share it.

Ladies and Gentlemen:  Please give your patients’ medications the attention required to ensure a safe and therapeutic outcome!

In reviewing clinical records for multiple clients, these are just a few of the things that I have seen with alarming frequency in the recent past:

  • An abundance of Tylenol ordered to the extent that patients took all that was ordered, they would likely die of liver failure.  But most don’t die of liver failure, so that begs the question of whether or not we are really checking medications as well as we should.
  • Far too many narcotics and sedatives in the elderly population.  If you stop and consider that falls are the number one cause of accidental death in persons greater than 65 yrs of age and that narcotics and other sedatives can only increase their risk of falls, all the little pieces start to add  up to a lot of dead  Medicare beneficiaries.  If that doesn’t disturb you (and the fact that it might not, disturbs me), then remember, you cannot bill on patients after the date of death.
  • Grossly inappropriate doses on the plans of care.  What’s wrong with these orders?
    • Scopolamine 10 mg i PO three times a day for dizziness.
    • Lortab 10/650 one or two tabs every 4 hrs prn pain
  • Duplicative drug therapy.  Seriously, how many inhalers does one patient need especially if they all contain albuterol?  Does Prilosec work better with Nexium enhanced by Zantac?  Did I miss an FDA alert?
  • Finally, how is it that a patient can go for an entire episode with no new orders for medications and yet the next 485 med list is radically different from the prior one?  Does the patient routinely go to the doctor the day before the recert visit and get his meds changed?  Surely, we aren’t missing any changes along the way.  That would be so unlike a good home health care or hospice nurse.

Sorry for the sarcasm.   I am barely keeping my head above water with all these clinical record reviews.  One thing for certain is that as more and more agencies go to computerized point of care charting, bad information is going to be even more readily available to caregivers.  And that scares me.

So, do me a favor.  Write a comment about a medication error or potential error that you caught before harm was done to the patient.  Tell the rest of us how you caught it and how you fixed it so we can learn, too.

May 11

The Dating Game

This is a game you don’t want to lose, folks. Before you read any further, take a minute and dispose of your date stamp.

In reviewing claims for ZPIC audits, multiple problems with dates have occurred. If the date stamp pre-dates the date that the physician signed his orders it appears to be blatant fraud. Only an idiot would do this, right? Wrongo. We see it so frequently we are appealing to the ICD-10 folks to have date stamp incompetency included as an official disease.

Next, consider the MD who has a date stamp that looks exactly like yours. This results in conflicting dates all over the same document. If I were looking for a reason not to pay a claim, I would have it on the first page of the 485. I could move on to the next claim saving myself a lot of time and effort reading through all the nursing notes. This happens more often than you think. There are three very popular date stamp formats out there. Nobody seems willing to have a date stamp custom made with their name on it.

What if the physician either doesn’t date his signature or does so in a manner that is illegible. Some British educated physicians still use the date format used in most other parts of the world. September 7 would read 7.9 in the UK. When this happens, CMS has given us a very useful tool to verify signatures and dates. It is called a signature attestation form. Please put the following on your letterhead and make a ton of copies. You will need them.

“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Notice this form can be used to verify both signatures and dates.

In the past, we have always operated under a rule that was not enforced. We were taught by our fiscal intermediaries and state offices that if a physician did not date his signature, we could simply indicate on the 485 or other order when the document was received in the agency. This is not how the CMS guidelines read and they are now enforcing the rule that the physician must date his signature. The only written exception would be in a hospital or other facility where multiple clinicians were documenting on the same piece of paper and a reasonable assumption could be made as to when the entry was made. This does not happen in home health or hospice.

This is worth repeating:

  1. Throw away your date stamp
  2. Ensure that your MD dates his signature
  3. If not dated, use attestation form.
  4. Have a signed and dated signature and attestation form in place prior to billing.

I promise that you do not want to lose the dating game.

Jan 5

We Don’t Know Everything!

Here is a list of things that nurses are not taught to any great degree in nursing school:

  1. Business Management
  2. Human Resources and management of people
  3. Quality Assurance
  4. Finances (thank you, God)
  5. Information Technology

Can you run an agency without any of these skills from all of your nurses? What have you done to increase your staff’s proficiency in these areas? If you are a nurse, have you taken any steps to educate yourself in these areas?

Years ago, the CEO of a very large, publicly traded health care company, implemented a policy that all business related books purchased by employees would be reimbursed by the company if the employee wrote a brief synopsis of the book and emailed it to him. I never knew if he was just trying to get around reading the books or if he truly wanted his staff to become well versed in business. Either way, I think it is a great idea. It’s pretty cheap, too unless you have a staff of Evelyn Wood’s speed reading graduates.

Is your education budget limited to OASIS and ICD-9 coding? What about PPS? Do your nurses fully understand how PPS works?

Managing people is difficult for many nurses including myself. We are wired to be compassionate. We tend to be too understanding the fifth time a nurse calls out sick after being seen out dancing by a coworker the night before. Putting systems in place that allow nurses to manage effectively helps them to make information based decisions rather than emotional ones. What systems do you have in place?

There is an entire Quality Assurance Industry out there with amazing publications and websites. In fact, there are studies that show that companies like Toyota and Southwest Airlines who spend the most on Quality Assurance are more successful. But before you can truly implement an effective Quality Assurance Plan, your staff must be educated on the processes. A Quality Assurance Nurse or a consultant cannot complete your Quality Assurance activities single handedly.

Cash and finances are not typically thought of a nursing issue until supply bills are too high or utilization is outside the stratosphere. And yet, when you consider that nurses have homes to run, bills to pay, etc., I think it is insulting to exclude us from financial decisions. We do not need to know how to prepare quarterly statements or cost reports but sharing financial data that is directly affected by nursing practices is a reasonable expectation. Agencies may just find that closer attention is paid to high dollar items and waste.

Finally, I cannot tell you how many times I have been called and asked how to download an attachment or found out that numerous emails I sent were never read because a nurse didn’t read email. When I teach Quality Assurance to a nurse and go to show her how to enter data into a spreadsheet, it is not unusual to find that her computer doesn’t have the software. I ask for reports from Lewis Computers which is used almost exclusively around here and no one seems to know what I am talking about even though I received the same report from a different client using the same System. All of this works for me because I am paid by the hour. The question is, does it work for you?

So, in keeping with the theme of staff development this week, I am encouraging you to develop these skills in your nurses. The organizations that hire any nurse with a license and treat nurses like disposable employees will be short lived as the demands on our industry grown tougher. And the agencies with lower turnover and competent staff will enjoy the challenges ahead.

And of course, if you need help establishing a plan to add to the overall competence in your agency, we are always available to assist by simply calling us at 225-2523-4876.

Send me your comments or email me if you have anything to add.

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