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Who does what in a nursing home? Part 2

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Who does what in a nursing home? Part 2

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nursing home personnelAttorney, Are you handling a nursing home case? Attorneys who litigate these kinds of cases should understand the nursing home staff’s roles. In a previous column, I identified the ancillary staff in a nursing home and specifically stated that across the board, none of them may perform hands-on care for the residents. The one exception task is feeding, and that may occur only if the office/ancillary worker received specific training by the facility.

So who does all the physical care of our elderly loved ones in a nursing home? The majority of care is given by the nursing assistants. They can be called aides, caregivers, C.N.A.’s (Certified Nursing Assistants), or care nurses. Whatever you call them, they are the backbone of any nursing facility. Whether the facility is for rehabilitation and therapy, assisted living, long-term care, or hospice, it generally falls to the nursing assistants to provide daily, sometimes hourly care.

It used to be that if you wanted to work in a hospital or long-term care facility, you got yourself hired and the facility taught you everything you needed to know in an orientation or training program. If you passed, then you could work for them. Now, aides must learn their skills from an accredited institution and be certified through comprehensive clinical and paper and pencil tests. The certification must be renewed each year through attendance at a required number of continuing education courses, usually 12, and proof of attendance must be submitted annually. Our facility offers these courses free of charge. Employers require a copy of the updated certification before hiring. Some nursing homes will only hire those with at least six months to two years previous experience in the field. There are others who are part of larger corporations owning multiple facilities who run an accredited training program to “grow their own staff.” In this case, the prior experience requirement is usually waived.

Nursing assistants must perform any task that the patient/resident cannot do for themselves with a few invasive exceptions. Aides prepare residents for breakfast with toileting or incontinence care, a quick wash-up, repositioning in bed or transferring them to a chair to eat. Nursing assistants help with dressing and grooming, bathing, other morning rituals, bedtime preparation, toileting, feeding, and transportation from one activity/location to another. For those who are physically challenged by disease, condition, trauma, or age and are totally dependent on another for every aspect of care and daily necessary activities, the nursing assistant will perform all tasks related to activities of daily living (ADL’s).

Aides provide fresh water and ice each shift (usually every eight hours), and keep resident’s personal belongings and the room as organized and safe as the resident will allow them. The aide must perform all these tasks while honoring the resident’s dignity, privacy, and personal preferences.

At our facility, aides ask each resident before lunch and dinner for meal preferences from the daily selections and get any changes to the dietary department to facilitate a timely substitution. A good nursing assistant is the eyes and ears of the nursing staff because they spend the most time with the residents. Where I work, aides have permanent assignments and they get to know every nuance of choice, ability and performance level of each person assigned to them. Part of their job is to immediately notify the licensed nurse of any change in skin condition, mental attitude, or physical/cognitive ability. The nursing assistant is usually the one who tells the nurse that “Mrs. Brown felt warm this morning, or Mr. Jones needed me to help him more than usual with dressing today.” Frequently, when a monthly or quarterly skill evaluation of a resident is due, the licensed nurse will go to the assigned aide for each shift for input on any changes that may have been noted.

Some residents/patients have special equipment and appliances for short or extended periods of time. These residents may have an appliance to assist with urine or fecal elimination. A Foley catheter or urostomy bag drains urine from the bladder. Aides may perform Foley care and empty a urine drainage bag, but not insert a catheter if it comes out. For residents with a colostomy for fecal elimination, aides may empty the bag and/or change it, but aides may not cut or measure the stoma covering attached to the skin in a two-part ostomy set up. Residents who are unable to take nourishment by mouth may have a tube inserted into the stomach called a “peg” tube. In our facility, an aide may put the pump running the tube on “hold” while care is being given, but not turn it off.

Nursing assistants may not perform any tracheostomy care or care related to intravenous (IV) or central catheter sites. A nursing assistant may not give a medication, injection, change a dressing, or perform an invasive test on a resident. They must defer all questions regarding care regimen, medication, or information on the resident’s chart to the licensed nurse.

At my facility, the staffing ratio is generally as follows: on day shift, one aide for 8-10 residents; for second shift, one aide for 15-18 residents, and on the night shift, one aide for 18-20 residents. When an aide calls in sick too late to replace her, the remaining aides have to take more patients.

The licensed nurse may be a licensed practical nurse (LPN) or a registered nurse (RN). The supervisor is usually an RN, but either may be a charge nurse. LPN’s may perform all aspects of care including giving medications and treatments, except an admission assessment (RN only). They can become IV certified and give medications through peripheral lines but not the first dose of any medication via IV, or infuse blood or blood products. Either nurse may speak to family members, the physician, consultants, take orders or lab results over the phone and take off orders from a written physician order. We usually staff one charge nurse for 20-30 residents around the clock.

A unit manager, usually an RN, is responsible for the smooth running of the activity and care on a unit (19 to 30 beds). This nurse prepares the unit paperwork (census and condition) and resident care plans (plan of care) and participates in the quarterly care conferences for each resident.

The director of nursing (DON) is the chief nursing officer in the facility and must be an RN. He or she is usually assisted by an assistant director of nursing (ADON) who is in charge in the absence of the DON. Their jobs are not usually hands-on care but comprised of policy formation, oversight, reports, meetings, discipline, education, hiring interviews, and more times than not, a lot of stress.

Our Nursing Home Expert witness earned a master’s degree in nursing from Thomas Jefferson University with emphasis on education and has been certified in gerontology for over 13 years. She has also worked for four years as a geriatric nursing expert witness with Med League legal nurse consulting analyzing  and evaluating medical records for attorneys related to potential litigation.

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