Vol. 5 Issue 9
Though regulations aren't as strict as in long-term care, assisted living nurses must take care in transferring residents
On paper, the condition of an assisted living candidate doesn't always tell the entire story.
His records may indicate he's in good health, with no serious illnesses or pressure ulcers to be found. But there are more telling factors such as limitations in activities of daily living (ADL) that really determine whether or not someone is appropriate for assisted living. It's an environment where LPNs and other nurses must be fluent in their abilities to recognize when prospective residents and those currently in-house need higher levels of care.
"It's all about being able to provide the appropriate level of care for someone," said Henri Carlton, MAS, RN, DON at Charlestown Retirement Community, Catonsville, MD, a member of Erickson Retirement Communities. "It is true you have to look at their clinical side, but you also have to look at how the resident communicates and functions physically."
Aside from resident safety issues, legal concerns can arise should someone fall, take an incorrect medication dosage or injure another resident because someone deemed them well enough to do certain activities on their own or go unsupervised around others.
In emergency situations where residents need to be temporarily transferred to a hospital and/or rehabilitation facility, it's especially important for proper assessments to be in place as a facility's sharing of information will directly affect the treatment a resident receives elsewhere.
ADVANCE recently spoke with assisted living nurses across the Mid-Atlantic region to determine how they effectively transfer their residents in and out of their respective facilities.
Contrary to popular belief, a physician referral or a sincere family request is not all that's needed to approve the admission of a person into an assisted living facility from an independent living facility or their home.
While transfer procedures, restrictions and regulations may vary from state to state (see sidebar), the admissions coordinators, nursing directors and LPNs ADVANCE spoke with did discuss a number of similarities within the admissions and discharge processes, especially as it applied to evaluation and paperwork.
Prior to being accepted for admission, residents at both Charlestown and Brandywine Assisted Living at Haverford (PA) Estates must undergo screenings that include chest X-rays and physicals to determine the presence of any communicable diseases or allergies that require medications. Per state regulations, facilities are also required to complete what's often referred to as a front sheet, or face sheet, for each resident entering their premises. Pertinent information to gather here includes, but is not limited to, a resident's date of birth, Social Security number, emergency contacts, insurance provider and physician. State regulations in both Maryland and Pennsylvania also hold that facilities conduct assessments within 30 days of resident admission to fully determine how to meet each particular resident's plan of care with regards to their ADL and cognitive abilities.
At both Charlestown and Brandywine, LPNs and RNs are responsible for providing such on-site assessments prior to resident admission, whether they're coming from home or another nursing facility.
"Hearing an assessment from a doctor, or receiving paperwork on a resident's condition, and seeing them with your own eyes are totally different things," said Alicia Somers, RN, staff nurse at Brandywine. "We'd rather have our staff, a known quantity, decide if someone is appropriate for our facility or if there are any exclusionary factors provided in the paperwork we receive on them."
An example of this could be the severity of a pressure wound, said Somers, who also is medical director at Main Line Adult Day Center, Bryn Mawr, PA. For instance, assisted living facilities in Pennsylvania cannot admit someone with a stage III or IV wound. This is also true of facilities in Maryland, Delaware and Virginia.
At Charlestown, RNs conduct initial resident assessments to determine whether they'd be best served in assisted living, while LPNs provide successive assessments that are routinely needed every 6 months at the facility's service plan meetings (unless needed sooner) to ensure that residents remain healthy enough for the level of care offered.
These assessments include documenting residents' vision, hearing, lung sounds, eating and sleeping habits, and range of motion, said Barbara Rush, LPN, an assisted living charge nurse at Charlestown. Rush participates in her facility's service plan meetings, which include the input of social workers, medical power of attorneys, residents and their families.
"We have a system in place where everybody knows their role," she explained.
WHEN IT'S TIME TO MOVE ON
Emergency situations and the natural aging process are both factors that impact a resident requiring more care, whether it's needed temporarily at a hospital or permanently within long-term care. But no mater the circumstances, proper procedures must again be followed before, during and after a resident relocates to another facility.
In the case of an emergency, aside from providing immediate care to the resident, assisted living staff must quickly contact the family and physician, and coordinate a transfer with emergency services and the hospital ED. Part of this process involves providing the hospital with a resident front sheet and emergency information sheet that lists his current meds and treatments prescribed, physician and nurses' notes relevant to current diagnoses, any known allergies and ADL concerns.
In Maryland, emergency information sheets also contain coding status for advance directives. Carlton describes this process as ensuring those transferring and receiving the resident have "baseline" knowledge of each resident.
"They need to have all information regarding what's normal for that particular resident," she explained. "Everything we provide the facility with will have an influence in the treatment the resident receives elsewhere."
It is also on the shoulders of the assisted-living facility to ensure that resident information is shared with a rehab facility if they require such treatment prior to return. This information is protected by HIPAA, Carlton said.
When residents plan their return to assisted living, Somers stressed the importance of communication with the hospital and rehab facility about any needed care-plan changes in addition to conducting its own assessment of the resident, to address the relevance of assisted living care.
"There are many aspects to deal with when helping residents and their families feel safe," said Somers, adding that the transfer process for residents moving into long-term care permanently is relatively the same as when going to a hospital. "A resident may not remember their medical history. They may not know why they have to take the 'blue' pill. They may not understand the strength of their medications. We have to help them understand and be as independent as possible."
Regarding moves into long-term care, a certain degree of difficulty can arise when residents and their families insist the transfer is not necessary, said Colleen Lewis, Charlestown admissions coordinator.
"We always consult with the family and try to make assisted living appropriate before moving a resident to a higher level of care," Lewis said. "But when a nurse or social worker recognizes a need for more staff assistance, medical condition changes or a resident's cognitive status declines beyond what this environment provides, we really try to let the family know that this change is in their loved one's best interest."
To avoid as few surprises as possible, Brandywine and Charlestown staff members conduct regular assessments on all residents. At Charlestown, an interdisciplinary team of nurses, social workers, medical directors and dieticians conduct weekly "high-risk rounds" to review how many nursing care hours each resident requires. Such issues can include incontinence, skin breakdown and weight loss, said Rush.
"There are many different things that can tell us it's time for a resident to go into long-term care," she added. "At that point, we discuss options, hold a service plan meeting with the family and take resident and family members on a tour of our long-term care facility, which is located on campus."
For those residents being transferred out of assisted living by a family member in a non-emergency situation, nurses are required to make sure the family member is listed as a contact for the resident and has valid identification, Rush said.
While nurses should always be aware of state-mandated procedures and how errors in judgment and diagnosis can lead to legal consequences, Somers said that nurses should always act on their instinct to do what's best for the resident.
"The best safeguard against any lawsuit is to provide good care for your residents and have a strong rapport with the family," she said. "We are very thorough in the way we document our assessments and incident reports."
Carlton added that staff should realize that times of transition are particularly stressful for residents and they may be reluctant to move. But a resident's pleading to remain in assisted living or enter assisted living in place of long-term care should never cloud a nurse's judgment.
"If you admit a resident who's not appropriate for the care you provide, you haven't done your due diligence and, then, it becomes a legal issue," Carlton said.
Assisted living staff working in the states where ADVANCE's Mid-Atlantic region covers (excluding Washington, DC) must undergo training and/or regular inservices to help maintain their competencies, which vary from state to state. (Visit www.ncal.org/about/statsum.htm for more details.)
"You're [the patients'] lifeline to what is needed for their care," Rush said. "They rely on you to do what's right every single day."
Joe Darrah is assistant editor at ADVANCE.
According to the National Center for Assisted Living, a branch of the American Health Care Association, all states within the Mid-Atlantic region (excluding New Jersey) have state mandated laws regarding the completion of resident assessments at admission and while in-house.
Below is a state-by-state rundown of certain conditions or circumstances that would necessitate a resident's discharge from or denial of admission to an assisted living facility. (Refer to www.ncal.org/about/statsum.htm for more information.)
Delaware: Includes those requiring "more than intermittent" nursing care. Other factors include if the person: is bedridden for more than 14 days; has stage III and IV skin ulcers; requires a ventilator, treatment for a disease that necessitates more than contact isolation, or an IV or central line; has an unstable tracheotomy; wanders excessively; or exhibits threatening or socially inappropriate behavior that is not manageable. Additional restrictions: if the person requires skilled monitoring, testing and aggressive med and treatment adjustments for an acute episode (unless an RN is available to provide care) or a chronic medical condition not stabilized through available meds and treatments.
Maryland: Restrictions for those requiring: more than intermittent nursing care; treatment of stage III and IV skin ulcers; ventilator services; skilled monitoring, testing and aggressive med and treatment adjustment of a fluctuating acute condition; monitoring of a chronic medical condition not controllable through readily available meds and treatments; treatment for an active, communicable disease or a condition that calls for more than contact isolation. A person also may not be admitted if they are deemed dangerous to self or others.
New Jersey: No entry requirements or restrictions. Mandatory
discharge is required for people who need specialized LTC, such as respirators, ventilators or severe behavior management. Facilities also may specify other discharge requirements such as if the person is bedridden for more than 14 consecutive days, requires 24-hour nursing care, is totally dependent on assistance for four or more ADLs, or is deemed a danger to self or others.
Pennsylvania: Restrictions for those permanently confined to a bed or who require: non self-care gastrointestinal feedings; treatment for stage III and IV skin ulcers; restraints, IVs or nasogastric feedings; or through assessment, are deemed to need a higher level of care.
Virginia: Those on ventilators, have stage III and IV skin ulcers, require nasogastric tubes, are considered a physical threat, or need continuous licensed nursing care may not be admitted.
Washington, DC: Restrictions for those who need professional nursing care, are unable to perform ADLs with minimal assistance or are incapable of proper judgment and are disoriented to person and place.
Source: National Center for Assisted Living