A: We hear this concern often from nurse leaders and medication nurses! Expecting one nurse to do vitals, meds, eye drops and handle interruptions is nearly impossible, especially with more than 30 residents. Because of multiple diagnoses, one resident can be on 18 different medications.

If you have more than one nurse on duty, have one handle care needs and other  interruptions, while the other passes meds. Train the staff which nurse to seek out while the med nurse is passing meds. Consider a medication aide, who may assist the nurse after being trained and passing any state- required tests.

Meet with your pharmacy and therapeutics committee. Are there medication times that can be changed? Can you schedule the 6 a.m. or 7 a.m. medication to be given from 6 a.m. to 10 a.m.? Expand dinner medications from 5 p.m. to 9 p.m.?

Are there any medications that you can combine or discontinue? As William Vaughan RN, BSN, has said, if you have a medication that requires you to sit your resident at a 90-degree angle for 30 minutes before giving the drug, then following the administration with 8 ounces of water, and you know your resident will be combative at 6 a.m., and will not tolerate sitting at a 90-degree angle for 30 minutes or drink a full 8 ounces of water, then talk to the pharmacist and medical director about discontinuing it. 

Keeping a medication scheduled, knowing you are unable to administer it correctly, is  setting your nurses and facility up for failure. 

Having a flexibly timed med pass, combining and discontinuing unneeded medication and limiting the med nurses’ interruptions will help you gain a better hold on your med pass times — and hopefully eliminate any future deficiencies.

A: This depends on several factors, including the individual’s specific medical condition, the policies and regulations (state and federal) of the facility, and the guidance of the medical or IP team.

Here are some considerations:

They can use the swimming pool if their colostomy is well-managed and they are stable.  However, it’s important to consult with their physician or nurse practitioner to assess any potential risks or concerns.

Proper care of the colostomy bag and stoma is crucial when using a pool. Waterproof ostomy pouch covers may be necessary to prevent water from compromising the seal of the colostomy bag. A nurse can provide guidance on maintaining a secure seal.

The facility should have specific policies regarding the use of any pool by residents with medical conditions like a colostomy. These may include requirements for medical clearance, supervision or precautions. 

The facility should supervise and assist residents in the pool area to ensure safety, especially if the resident requires assistance with their colostomy. It’s important that staff members are adequately trained and available to provide support in situations like these. Maintaining proper hygiene and infection control measures in the pool area also is crucial. 

Each resident’s situation is unique, and  his or her ability to use the swimming pool should be assessed on an individual basis.

Factors such as mobility, balance and any other medical conditions should be considered with this assessment. Keep in mind, too, that the above factors are liable to evolve over time for long-time residents. Staff clinicians should make a point of regularly re-evaluating each patient’s conditions and abilities.

A: Bravo to you for teaching staff to spot a potential problem before it becomes one!

For doffing and donning, perhaps use shaving cream or a glo-germ type product if you have a black light for the “glo” product. Spray shaving cream on the gloves and gown of the staff member and ask them to remove the gown and gloves correctly and dispose of them.

If done correctly, the shaving cream will be contained in the gown and gloves. If the shaving cream escapes, you know that the employee needs further education.

You can use just about anything like pudding, whipped cream or jelly to mark the gown and gloves. But we found shaving cream was easily cleaned if it dropped onto the floor or got on clothing.

For recognizing a potential problem,  I set up a room (awaiting an admission). I would put a Foley bag laying on the floor, put a toothbrush uncovered on the bathroom sink, uncovered oxygen tubing, rotten fruit in the drawer … also a commode with apple juice in it (resembling a commode that needed to be emptied), a filthy wheelchair, a disposable soiled with chocolate pudding in the bedside trash, and pills on the bedside.

We would have 10 to 15 items we identified as a problem and told staff who worked in pairs, to write down the 15 problems. We timed them. Those who recorded all of the problems were kept to the side. 

At the end of the day, the top five fastest with all correct answers won a gift card. Usually to a coffee or tea retailer. The staff loved this game and we had different themed rooms — testing safety, infection control, etc.

Make it fun or serve food — but NOT PIZZA — and they will attend!

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

A: For the insulin pens commonly needed by diabetic patients, remember they are to be used on an individual resident, one pen per resident, and only under a physician’s orders, of course.

Those pens should be stored in separate bins in the med cart. 

If they can’t be stored in a separate plastic bin, you must store them in individual plastic bags (usually provided and labeled by your pharmacy). The resident’s name must be on the bag and some states are requiring a label on the pen/syringe too. Check your state’s regulations and make sure your facility policy aligns.

Some may still have questions, such as if we change the needle and wipe off the syringe with an antimicrobial wipe, can the one syringe be used on more than one resident? 

The answer is a hard and firm NO! Under no circumstance can a syringe be used on more than one resident.

When it comes to storing your oxygen tubing, remember that plastic bags breed bacteria.

Try using a WikiPouch (to be clear, I do not work for them). The WikiPouch is composed of a breathable material with a place on the bag for the resident’s name and a drawstring to hang the contents.

You know plastic bags need to be taped onto something to keep them from landing on the floor. As an alternative, nurses can place tubing in the resident’s bedside cabinet drawer, a solution we also have seen work well. 

You can request a WikiPouch sample from the company’s website, which is also a good resource. The company can provide research showing its storage product reduces healthcare-associated infections, which is the dream of every infection preventionist!

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

A: You are understanding correctly, as routinely changing Foley catheters is an outdated practice. Unfortunately, this outdated practice still exists in many facilities. I suggest you look at CAUTI bundle compliance, along with a rounding tool. 

Bundle (ABCDE) Checklist for Prevention of CAUTIs

• Hand hygiene: It is the most important factor in preventing nosocomial infections.

• Aseptic catheter insertion procedure.

• Proper Foley catheter maintenance, education, and care by nursing staff.

• Foley catheter use surveillance and feedback

Urotoday.com also offers resources to help you with the ABCDEs of catheters and catheter care; it’s quite helpful. Perhaps your infection preventionist can add a rounding to check the condition of Foleys and identify maintenance needs. 

Ask a care team member if the Foley is still warranted or if a patient could be weaned. 

Get your team involved so that the numbers of catheters, their maintenance and the rounding needed to monitor them is a team approach and everyone is involved. 

Make it a team goal through your QAPI meetings to reduce the number of catheters if you think, or know, the number of Foley catheters is higher than normal for your census.

As a leader, when you see the need for a change to improve the quality of care and or life at your facility, it is your responsibility to start the ball rolling, no matter if a regulation is or is not involved. It’s the right thing to do.

Sherrie Dornberger, RN, CDONA, FACDONA, is executive director of NADONA. Send her your resident care questions at ltcnews@mcknights.com.

A: You don’t have to do it all alone!

Think about some of the best training you have received, and try recreating some of it. Skills labs are popular with staff. Set up a room with blood pressure stations, a weigh station and more. and have nurse aides go through the stations.

Set up a room with 10 things that are wrong — maybe a frayed call light, items on the floor, pills on the bedside table — and have staff list the items that should not be there or are dangerous. Or send emails to your consultants, medical director, dietitian and social worker, and give them a month during the year that you would like them to conduct an in-service. 

For instance, perhaps ask the dietitian to talk about proper seating and feeding of the resident. Ask podiatry to speak on care of the feet. A pharmacy consultant can perhaps address flexible medication times. Also involve the social worker, funeral director, local politician and administrator.

Do you have nurses who are certified in wound care or infection prevention? Include them, too. This way, lots of people make your work lighter. 

Activities can get involved, too, talking about activities and how they involve residents and perhaps their family members in selecting appropriate activities for the specific residents. These session can provide new lessons for consultants too, as the staff know their residents well and can make suggestions to improve the quality of life for those under their care.

Make it fun. Serve refreshments when you can, and more will attend! Oh, and don’t make all of the training at 2 p.m. just to make it easy for the consultants. Juggle the times so all shifts have equal opportunities to attend during their waking hours.

A: Sometimes residents who have Alzheimer’s or dementia have picking problems, picking at their skin or clothing they may be wearing. 

There are thick elastic arm and leg covers you can purchase to keep those areas covered. Keeping the skin from drying out also will help. 

Document on the care plan whatever you have done — no matter whether it’s worked or not — for a particular resident. That will help new staff understand how to dress the resident, or apply moisturizer to the areas they tend to pick.

If you have someone who does nails in the facility, or someone takes the resident to a nail salon, you can not only have the nails trimmed and filed but there is a powdered application called an SNS nail treatment. Once applied, the nail is thicker and dull with more rounded edges, making picking less possible. The treatment usually stays on and can be reapplied about every three weeks. 

We had SNS applied with a family’s or power of attorney’s permission, and it made a huge difference with skin picking. One family transported their resident to the nail salon, and one of the family members for another resident was a nail technician and would come visit and fix her grandmother’s nails with an SNS treatment.

We care planned everything and their skin looked great within a few months after applying the nail treatment.

Start with baby steps and get the family and/or POA involved if the resident can’t make decisions on their own. Sometimes, traditional arm covers or moisturizer will be your answer.

As we know, every resident responds differently to different approaches.

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

A: Congratulations on your new position! I would look up the Centers for Disease Control and Prevention tools in Project Firstline. It is laid out to assist you as the IP, and to allow you to pull interactive video and print training materials for your staff.

There also are YouTube videos explaining  elements of the Firstline program. It strives to ensure everyone realizes that Infection prevention is an “essential” part of caring for and protecting patients. 

“When you can understand and apply infection control actions consistently and confidently — every person, every action, every day — it saves lives,” organizers said.“CDC’s Project Firstline provides innovative and accessible resources so all healthcare workers can learn about infection control in healthcare [and] about where germs live in healthcare settings and how to recognize the risk for them to spread — which is the first step in understanding when to take action to protect your patients and yourself from infections.”

As a healthcare provider, you’ll learn to recognize infection risks — and take action “to protect your patients and yourself, no matter the situation.”

Taking this course gives you confidence in knowing you are providing the best possible and safest care for your residents.

If you love IP and want to be further credentialed, there are other courses and certification exams available through NADONA, CDC and APIC. Which you choose just depends on the amount you want to spend obtaining the certification, and whether you prefer taking self-paced online classes or learning in person.

Post-acute care needs more supportive, well-trained staff, so thanks for being so diligent.

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

A: This is definitely the most asked question at the moment. It seems that the facilities that have had some success have made several specific moves. Meet with your staff, one-on-one and ask where the help is most needed.

Look at your medication pass time and the number and type of meds being passed. See if you can combine some of the med passes, as many facilities have meds every hour, which potentially can keep a floor nurse anchored to the cart for her entire shift. 

Meet with the medical director and other physicians to see what meds you can move, combine or discontinue.

Think about scheduling and hiring nurses for three- , four- , or six-hour shifts. Maybe there are some moms who can work only while their kids are in school — or after the kids go to bed. Or there’s a nurse getting her degree and only has a few hours here and there. Hire them! Give your overworked nurses some assistance!

Same with nurses aides. Perhaps hire some high school students to pass water and ice, deliver the mail, read the mail, make the beds or tidy up the rooms. They may love what they are doing and decide to become certified or even apply to nursing school. Bring them in during your busy times, or activities times. Many high school groups, such as the Future Nurses of America, may be perfect, or approach church youth groups and the Girl Scouts and Boy Scouts.

I know thinking out of the box can be hard to do and hard to be accepted by others, but it could be a way to help you. It bears stating that raising salaries, granting paid time off and offering incentives also helps!

A:  Enhanced barrier precautions have certainly caused a stir in the profession, especially among the nurse leaders who write and are responsible for the facility policies.

The Centers for Medicare & Medicaid Services has stated that it is not surveying for enhanced barriers as yet, but at least two states currently are surveying for them on their own. 

I will also say, don’t shoot yourself in the foot by writing  your policy with too many promises. 

For instance, don’t claim to have enhanced barrier precautions on every cut or skin tear in your building. You know the day the surveyor arrives you will have a new skin tear and someone will not have on enhanced barrier precautions and care for the resident Remember: Surveyors will be looking for the difference between the care and the policy.

Contact precautions 

Gown and gloves for all rooms and all activities

Private room ideal

Room restriction except for medically necessary care

Recommended to be time limited

Enhanced barrier precautions 

Gown and gloves for only high-contact resident care

No Private room

No room restriction and may participate in community activities

Recommended for duration of stay

Check the CDC website at CDC.gov for more information on enhanced barrier precautions. You will find great resources!