The Nursing Assistant Working in Long-Term Care Chapter 1 The Nursing Assistant Working in Long-Term Care All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Resident-Focused Care Your focus is the resident—the person needing care. You must provide quality care and promote the person’s quality of life and independence. Independence means not relying on or requiring care from others. Persons in long-term care centers are called residents, not patients. They are called residents because the center is their temporary or permanent home. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Long-Term Care Centers Long-term care centers provide health care to persons who cannot care for themselves at home but do not need hospital care. Board and care homes (residential care facilities) provide rooms, meals, and laundry to a few independent residents in a home-like setting. Assisted living residences (ALRs) provide housing, personal care, support services, health care, and activities in a home-like setting. Long-term care residents are older or disabled. Some are recovering from illness, injury, or surgery. Some return home when well enough. Other need nursing care until death. Board and care are more independent. Board and care homes provide care that meets the person’s basic needs. Assisted living residences can look similar to apartment buildings. Some are part of retirement communities or nursing centers. Help is given as needed with personal care, meals, or taking drugs. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Nursing Centers Nursing centers (nursing facility [NF], nursing home) provide health care and nursing care to persons who need regular or continuous care. Licensed nurses are required. Skilled nursing facilities (SNFs) provide health care and nursing care for residents who have many or severe health problems or who need rehabilitation. Purposes and goals include: Promoting physical and mental health Treating chronic illness Preventing communicable diseases Providing rehabilitation or restorative care Note that a chronic illness is an ongoing illness, slow or gradual in onset. It has no cure. The illness can be controlled and complications prevented with proper treatment. An acute illness is a sudden illness from which the person is expected to recover. An acute illness may require hospital care. Other services may include hospice or Alzheimer’s units. Hospice focuses on comfort—including the physical, emotional, social, and spiritual needs of the person—not cure. Alzheimer’s units are for persons with Alzheimer’s disease and other dementias. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Nursing Center Organizational Structure Nursing centers are owned by an individual, a corporation, or county health departments. Each center has an administrator. The department directors report to the administrator. By law, nursing centers must have a medical director. The owners must make sure that safe care is provided. Local, state, and federal rules must be followed. Most nursing centers have nursing, therapy, and food service departments, plus housekeeping, maintenance, and laundry departments. A human resources director handles personnel matters such as hiring staff. A finance director handles resident billing. A social services director meets the social needs of residents and families. An activity director plans resident activities. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Nursing Service Organization The director of nursing (DON) is responsible for the entire nursing staff. Nurse managers (usually registered nurses [RNs]) assist the DON. Staff RNs report to the charge nurse. Licensed practical nurses (LPNs)/licensed vocational nurses (LVNs) report to staff RNs or to the charge nurse. You report to the nurse supervising your work. Nursing education staff (staff development) is part of nursing science. Shift managers coordinate resident care for a certain shift. Other managers are responsible for a nursing area or a certain function, such as staff development, restorative nursing, infection control, or continuous quality improvement. Nursing education handles a wide variety of duties, from in-service programs to training nurse assistants. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

The Nursing Team The nursing team involves those who provide nursing care. RNs, LPNs/LVNs, and nursing assistants A registered nurse (RN) assesses, makes nursing diagnoses, plans, implements, and evaluates nursing care. A licensed practical nurse (LPN) requires little supervision when the person’s condition is stable and care is simple. With acutely ill persons and with complex procedures, the LPN assists the RN. Nursing assistants give basic nursing care under supervision of a licensed nurse. Nursing assistants give much of the care provided in nursing centers. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

The Interdisciplinary Health Care Team Involves the many health care workers whose skills and knowledge focus on the person’s total care The overall goal is quality resident care. Coordinated care is needed. An RN leads the team. Many staff members work together to provide a person’s care, each with a different role. Health team members must communicate often. If you have questions or concerns about a person and his or her care, tell the team leader. The leader will communicate with other health team members. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Paying for Health Care Private insurance is bought by individuals and families. Group insurance is bought by groups or organizations for individuals. Medicare is a federal health insurance program for persons 65 years of age or older. Part A Part B Medicaid is a health care payment program sponsored by the federal government and operated by the states. Providing health care to everyone and reducing the high cost of care is a major focus in society. Hospital and nursing center care is costly, as are doctor visits, drugs, medical supplies, and home care. Most people cannot afford these costs, so some avoid medical care because they cannot pay; others pay doctor bills but go without food or drugs. Health care bills cause worry, fear, and emotional upset. If the person has insurance, some costs are covered; rarely is the total cost covered. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Prospective Means Before Care Prospective payment systems Diagnosis-related groups (DRGs) are for hospital costs. Resource utilization groups (RUGs) are for SNF payments. Case mix groups (CMGs) are used for rehabilitation centers. Managed care limits: The choice of where to go for health care The care that doctors provide Prospective payment systems limit the amount paid by insurers, Medicare, and Medicaid. Types of managed care Health Maintenance Organization (HMO) provides health care services for a prepaid fee, focuses on preventing disease and maintaining health. Keeping someone healthy costs far less than treating illness. Preferred Provider Organization (PPO) is a group of doctors and hospitals that provide health care at reduced rates. Usually the agreement is between the PPO and an employer or an insurance company. Employees or those insured receive reduced rates. The person can choose any doctor or hospital in the PPO. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

All items and derived items © 2015, 2011 by Mosby, Inc All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Meeting Standards Standards for nursing centers are set by: Federal and state governments Accrediting agencies A center must meet standards for: Licensure (issued by the state) Certification Accreditation Standards relate to center policies and procedures, budget and finances, and quality of care. A center must meet standards for: Licensure; a license is issued by the state. A center must have a license to operate and provide care. Certification is required to receive Medicare and Medicaid funds. Accreditation is voluntary. It signals quality and excellence. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 18

The Survey Process & Your Role Surveys are done to see if the center meets set standards. You must: Provide quality care Protect the person’s rights Provide for the person’s and your own safety Help keep the center clean and safe Conduct yourself in a professional manner Have good work ethics Follow center policies and procedures Answer questions honestly and completely The survey team decides if the center meets the standards. If standards are met, the center receives a license, certification, or accreditation. If problems are found, they are called deficiencies. The agency is given time (up to 60 days usually) to correct it. The agency can be fined for uncorrected or serious deficiencies, or it can lose its license, certification, or accreditation. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19

Nursing Assistant Duties To protect residents from harm, you need to know: What you can and cannot do What is right conduct and wrong conduct Your legal limits Your work is shaped by: Laws Job descriptions The person’s condition The amount of supervision you need What concerns do you have about your legal limits? Have you decided in which state and location you plan to work? All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 20

History and Current Trends Until the 1980s, nursing assistant training was not required by law. Before the 1980s, team nursing was common. Primary nursing was common in the 1980s. Home care increased during the 1980s. Efforts were made to reduce health care costs. Until the 1980s, nurses gave on-the-job training. Some hospitals, nursing centers, and schools offered nursing assistant courses. Before the 1980s, a registered nurse (RN) was the team leader who assigned care to nurses and nursing assistants. Care was assigned according to each person’s needs and condition. It also depended on the staff member’s education and experiences. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 21

Federal and State Laws You must know the state and federal laws that affect your work. Each state has a nurse practice act that: Defines RN and LPN/LVN Describes the scope of practice for RNs and LPNs/LVNs Describes education and licensing requirements for RNs and LPNs/LVNs Protects the public from persons practicing nursing without a license Allows for revoking or suspending a nurse’s license The US Congress makes federal laws that all 50 states must follow. State legislatures make state laws. You must know the federal and state laws that affect your work. They provide direction for what you can do. The nurse practice act for each state protects the public’s welfare and safety by regulating nursing practice in that state. Persons who do not meet the state’s requirements cannot perform nursing functions. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 22

Nurse Practice Act and Nursing Assistants A state’s nurse practice act is used to decide what nursing assistants can do. The Omnibus Budget Reconciliation Act of 1987 (OBRA) applies to all states. It sets minimum training and competency evaluation requirements for nursing assistants. It requires each state to have a nursing assistant training and competency evaluation program (NATCEP). The training program OBRA requires at least 75 hours of instruction. There must be 16 hours of supervised practical training. Some nurse practice acts also regulate nursing assistant roles, functions, education, and certification requirements. Other states have separate laws for nursing assistants. The purpose of OBRA is to improve the quality of life of nursing center residents. A nursing assistant must successfully complete a NATCEP to work in a nursing center, hospital long-term care unit, or home care agency receiving Medicare funds. Students perform nursing care and tasks on another person. A nurse supervises this practical training (clinical practicum or clinical experience). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 23

OBRA Basics Competency evaluation The competency evaluation has a written test and a skills test. The written test has multiple choice questions. The skills test involves performing nursing skills. The nursing assistant registry is an official record of persons who have successfully completed a state-approved NATCEP. All information stays in the registry for at least 5 years. Any agency can access registry information. You receive a copy of your registry information. Other OBRA requirements Retraining and a new competency evaluation program for nursing assistants who have not worked for 24 months 12 hours of educational programs for nursing assistants every year Performance reviews A state’s nursing assistant registry is an official record or listing of persons who have successfully completed that state’s approved NATCEP. Any agency (hospital, nursing center, home care agency) can access registry information. You also receive a copy of your registry information. The retraining and competency requirements help ensure that you have the current knowledge and skills to give safe, effective care. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 24

Certification After successfully completing your state’s NATCEP, you have the title used in your state. Certified nursing assistant (CNA) or certified nurse aide (CNA) Licensed nursing assistant (LNA) Registered nurse aide (RNA) Nursing assistants can have their certification (licenses, registration) denied, revoked, or suspended. Each state NATCEP must meet OBRA requirements. If you do something beyond the legal limits of your role, you could be practicing nursing without a license. This creates serious legal problems for you and the nurse supervising your work. Review the reasons listed by the National Council of State Boards of Nursing (NCSBN) for revoking or suspending a certification (license, registration) on page 11. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 25

Working in Another State To work in another state, you must meet that state’s registry requirements. To do so, contact the state agency responsible for NATCEPs and the nursing assistant registry. Then apply to the state agency to be a CNA (LNA, RNA). Your application is reviewed to see if you meet the state’s requirements. The application review results in one or more of the following: Being granted or denied certification (a license, registration) Having to take a competency test. This may be the written test, the skills test, or both. Having to take a NATCEP in that state. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 26

Roles and Responsibilities The following direct what you can do: Nurse practice acts OBRA State laws Legal and advisory opinions To protect persons from harm, you must understand: What you can do What you cannot do The legal limits of your role In some states, this is called scope of practice. The National Council of State Boards of Nursing (NCSBN) calls it range of functions. Licensed nurses supervise your work. You assist them in giving care. You also perform nursing tasks related to the person’s care. A nursing task is the nursing care or a nursing function, procedure, activity, or work that can be delegated to nursing assistants when it does not require an RN’s professional knowledge or judgment. Review the rules in Box 1-3 on p. 12. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 27

Roles and Responsibilities (Cont’d) Licensed nurses supervise your work. You assist in giving care. You also perform nursing tasks. Before you perform a nursing task, make sure that: Your state allows nursing assistants to do so. It is in your job description. You have the necessary education and training. A nurse is available to answer questions and supervise you. Often you will function without a nurse in the room. At other times you help nurses give care. In some centers, you assist doctors with procedures. The range of functions for nursing assistants varies among states and centers. Review Boxes 1-3, 1-4, and 1-5 on pp. 12-13 for rules and role limits for nursing assistants. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 28

Nursing Assistant Standards OBRA defines the basic range of functions for nursing assistants. All NATCEPs include those functions. Some states allow other functions. NATCEPs also prepare nursing assistants to meet those standards. Review the contents of Box 1-5 on p. 13. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 29

Job Description The job description: Is a list of responsibilities the center expects you to perform It also states educational requirements Always request a written job description when you apply for a job. Do not take a job that requires you to: Act beyond the legal limits of your role Function beyond your training limits Perform acts that are against your morals or religion Clearly understand what is expected before taking a job. Refer to Figure 1-5 on pp. 14-15. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 30

Know Your Limits No one can force you to do something beyond the legal limits of your role. You must understand: Your roles and responsibilities The functions you can safely perform The things you should never do Your job description The ethical and legal aspects of your role State laws and rules limit nursing assistant functions. Your job description reflects those laws and rules. A center can further limit what you can do; so can a nurse based on the person’s needs. However, no center or nurse can expand your range of functions beyond what your state’s laws and rules allow. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 31

Delegation Delegate means to authorize another person to perform a nursing task in a certain situation. The person must be competent to perform a task in a given situation. Who can delegate? RNs can delegate tasks to LPNs/LVNs and nursing assistants. In some states, LPNs/LVNs can delegate tasks to nursing assistants. Nursing assistants cannot delegate. Delegation decisions must protect the person’s health and safety. The delegating nurse is legally accountable for the nursing task. Accountable means to be responsible for one’s actions and the actions of others who performed the delegated tasks. The delegating nurse must make sure that the task was completed safely and correctly. If the RN delegates, the RN is responsible for the delegated task. If the LPN/LVN delegates, he or she is responsible for the delegated task. The RN also supervises LPNs/LVNs. Therefore the RN is legally accountable for the tasks that LPNs/LVNs delegate to nursing assistants. The RN is accountable for all nursing care. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 32

The Delegation Process The National Council of State Boards of Nursing (NCSBN) describes the delegation process in four steps. Assess and plan: The nurse needs to understand the person’s need. Communication: The nurse must provide clear and complete directions. Surveillance and supervision: The nurse must make sure that you complete the task correctly. Evaluation and feedback: The nurse decides if the delegation was successful. The Five Rights of Delegation (according to the NCSBN) The right task The right circumstances The right person The right directions and communication The right supervision To make delegation decisions, the nurse follows a process. The person’s circumstances are central factors in delegation decisions. Delegation decisions must result in the best care for the person. Otherwise the person’s health and safety are at risk. Also, the nurse may face serious legal problems. If you perform a task that places the person at risk, you may face serious legal problems. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 33

Accepting a Task When you agree to perform a task: You are responsible for your own actions. You must complete the task safely. You must ask for help when you are unsure or have questions about a task. You must report to the nurse what you did and the observations you made. You must protect the person from harm. You have two choices when a task is delegated to you. You either agree or refuse to do the task. Use the Five Rights of Delegation in Box 1-6, p. 17. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 34

Refusing a Task You should refuse to perform a task when: The task is beyond the legal limits of your role. The task is not in your job description. You were not prepared to perform the task. The task could harm the person. The person’s condition has changed. You do not know how to use the supplies or equipment. Directions are not ethical or legal. Directions are against center policies. Directions are unclear or incomplete. A nurse is not available for supervision. You have the right to say “no.” Never ignore an order or a request to do something. Tell the nurse about your concerns. If the task is within the legal limits of your role and in your job description, the nurse can help increase your comfort with the task. Do not refuse a task because you do not like it or do not want to do it. You must have sound reasons. Otherwise, you place the person at risk for harm. You also could lose your job. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 35

Quality of Life Nursing center care is always focused on the resident. Residents should be allowed to do as much for themselves as safely possible. The work you do is important for the person’s quality of life. Your current training is just the start of a lifetime of learning and possibilities. The interdisciplinary health care team helps all residents to become or remain as independent as possible to promote their quality of life. Do not do or take over tasks that residents can do themselves. Allowing them to do as much for themselves as safely as possible helps their feelings of independence. Some states have higher levels of nursing assistants. Medication Assistant-Certified (MA-C) is an example. MA-Cs are nursing assistants with extra training. Supervised by a licensed nurse, they give drugs as allowed by state law. The work you do has value. By continuing to learn, you increase your skills and knowledge. It adds to your value. It offers you more opportunities. Be proud of your training and never stop learning! All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 36