CCC Plan of Correction CNA 2014

Objective At the completion of this module the staff will be able to: Identify two ways of maintaining resident privacy. State two “do’s” and two “don'ts” of documentation. Describe three behaviors that determine pain.

Resident Privacy Maintaining resident privacy of body includes: Pulling the curtains completely around the resident’s area until the curtains touch the wall at both ends. Pulling window shades/curtains when caring for the resident. Never close the door of the room.

Resident Privacy Maintaining resident privacy of body includes: Keeping residents sufficiently covered. While being taken to areas outside their room, such as the bathing area, keep them dressed.

Documentation Proper nursing documentation will ensure that the residents receive the highest quality and correct care in response to their symptoms. Legally speaking, proper nursing documentation will help you defend yourself in a malpractice lawsuit, and can also keep you out of court in the first place.

Documentation-Do’s Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities. Write legibly. Chart the time you gave a medication, the administration route, and the patient's response. Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response. Chart patient care at the time you provide it. If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

Documentation-Don’ts Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a patient's record - this is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't write imprecise descriptions, such as "bed soaked" or "a large amount." Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

If you didn’t document it, it wasn’t done Documentation Remember…. If you didn’t document it, it wasn’t done

Pain Management Documentation Residents have the right to the appropriate assessment and management of pain. 1 2 3 4 5 6 7 8 9 10 No Pain Mild Pain Moderate Pain Severe Pain Worst Possible Pain should be measured using an assessment tool that identifies the quantity and/or quality of the residents’ experience of pain.

Examples of Behaviors which may indicate pain: Facial: grimacing, clenched teeth, frowning, tearing, glazed eyes, turned down mouth Vocalization: moaning, crying, grunting, gasping, screaming, cursing  Body action: thrashing, rocking, pounding, holding/rubbing body parts, altered breathing/ posture 

Pain Documentation At the time you reassess the resident to determine if the pain was relieved, you will use the same identified behavior that you used to assess the need for pain medication to determine if the intervention was effective. Example: No further s/s of pain –no grimacing or moaning When you assess a resident in regards to pain, and you determine that the resident is in pain because of one of the listed behaviors, you document your assessment. Example: s/s of pain -grimacing and moaning

Storing Supplies 18” When storing items on shelves, there needs to be a 18” space between the item and the ceiling. No items should be stored within 18 inches from the ceiling

Thank You