US nursing homes would have three years to provide a minimum of 3.0 hours of nursing care per day, at least 0.55 hours of that by a registered nurse and 2.45 hours by a nurse aide, under a first-ever federal staffing mandate proposed Sept. 1.

Non-rural nursing homes would have three years to comply with the 3.0 standard, while rural facilities would have five years, the Centers for Medicare & Medicaid Services said.

A requirement of 24/7 RN coverage — triple the current standard — would take effect for urban providers two years after the rule is finalized, three years for rural providers.

The proposal includes an option for hardship waivers, an element pleaded for by providers, who nonetheless railed against the demands for more staffing amid record staffing shortages. An estimated 75% of providers would need to add staffing to comply, officials said. Comments are due by Nov. 6.

A: Nursing homes were able to fairly quickly improve their CNA staffing after receiving a PPP loan, which equated to two additional shifts per week one month after receiving a loan and four additional shifts per week six months after receiving a loan. They not only increased staffing with those dollars, they significantly increased it.

Q: You’ve been granted $3.7 million to continue examining these and similar effects over the next five years. What’s the next area of focus?

A: With our next study, we will be able to see how that funding affected staffing stability and staffing tenure, which is found to be an even more reliable indicator of quality. And we’ll also look at the impacts on dementia residents because they do require more staff attention, more direct care, especially as we try to get away from pharmacological interventions. 

The overall goal is to develop a framework to guide future nursing home responses to public health emergencies that will improve staff patterns and resulting outcomes for residents with Alzheimer’s disease and other dementias in low-resourced neighborhoods. For that work, we’ll be looking at staffing data and interviewing nursing homes across the US.

Q: The public health emergency is over. Why continue to study the reach of COVID-related funding for the SNF sector?

A: It is really important to focus on minimum staffing standard expectations. But we also have to make sure that nursing homes are able to hire. With this research, we’re able to see programs [resulting from extra funding] as a model. The question is, where are the staff coming from, and what support do they need to attract them? That’s the gap we have.

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: Not necessarily! 

Extensive work is done in assessment, identification and treatment of a pressure ulcer to understand the patient‘s needs and avoid F-Tag 314.

The key to success is to have the skin assessment at the initial assessment. It is a good practice to use standardized tools, such as the Braden Scale, to assess the nutritional status, cognitive status, swallowing difficulties, dental status, medications, comorbidities and immobility that could prevent wound healing. 

Many patients have venous, arterial or neuropathic diseases that may affect the circulation in the lower extremities, consequently leading to ulcers. Patient history also should be acquired. Ballet dancers and soldiers may end up with undesired foot problems due to prolonged standing or uncomfortable footwear use in the past.

 Another key factor is that older adults may not have access to fresh fruits or vegetables, which can lead to nutritional deficiencies and avoidable skin breakdown. That can occur in areas of previously healed ulcers due to decreased tensile strength of scars. 

The location of the wound with associated symptoms is an important aspect of initial assessment. For example, arterial ulcers are punched out and circular with mild drainage, while venous ulcers are shallow with ragged edges and profuse drainage. Neuropathic ulcers are painless for the most part, though they may have associated neuropathic symptoms in other parts of the body. Frequently, there are multiple factors that lead to wound formation. While a few may be modifiable, many are not. 

In conclusion, it is essential to know the medical, cultural, economic, educational and psychosocial background of one’s patient. This will allow a thorough person-centered understanding and therapeutic healing with the patients.

Please send your wound care-related questions to Dr. Naqvi at ltcnews@mcknights.com.

The technology’s advice mirrored clinician assessments in more than 90% of cases in a study by Loma Linda University and University of California Berkeley researchers.

A total of 80 patients were evaluated by a wound care provider who, after forming his own treatment plan, used chatbot software to personalize treatment. Providers interacted with the chatbot through a natural language interface, providing patient info, wound characteristics, and medical history.

“Traditional wound care approaches require extensive expertise and experience to navigate the complexities of wound assessment, diagnosis, and treatment,” researchers wrote in Wounds. “This technology enables wound care providers to access real-time knowledge, augment their decision-making, and enhance patient outcomes. By leveraging AI software, providers can access a vast knowledge base, ensuring accurate diagnoses and treatment recommendations tailored to each patient.”

Such barriers range from ongoing policymaking around telehealth; ethical challenges in virtual information and communication technology; social challenges; cost and payment concerns; cultural issues; and insufficient knowledge of virtual care scope of practice.

That’s according to a team of Iranian researchers, who examined existing literature and interviewed wound care clinicians about the problems they’ve experienced in extending care virtually after patient discharge.

“In order to successfully develop a virtual care programme, it is necessary to adopt suitable policies regarding information and communication technology, provide the necessary legal frameworks, assign an adequate budget and consider the ethical, cultural and social issues,” they wrote in NursingOpen in late August. “Identifying barriers to developing a virtual care programme will help manage patients with chronic wounds at home.”

A:The Centers for Medicare & Medicaid Services form CMS-20058, QAPI and QAA Pathway, which surveyors use, is a great way to structure staff QAPI education so it includes all necessary components. 

Staff must be engaged in the QAPI efforts and understand what QAPI efforts the facility is working on and why. Nurse leaders could post this information in the break room or provide it during staff meetings, being sure to identify a contact for questions on quality improvement efforts. 

Once staff understand what QAPI is and how the facility is implementing it, there are many ways to increase participation. First, highlight avenues to raise concerns  about processes or policies. Often, staff see potential issues before problems occur, but they must feel safe to share those issues.

Emphasize that all ideas and concerns are welcome so that facilities can make changes before problems occur. Consider designating a place where staff can submit comments and concerns about quality issues if they are uncomfortable coming directly to leadership. 

During the QAPI process, solicit staff feedback regarding changes that affect them. Staff can provide valuable input by helping test, sustain and reflect on changes. Since staff are closest to the work, they can advise on whether changes in practice work. Staff also can help monitor data trends. For example, the restorative nurse may be able to identify in real time any changes in activities of daily living so the facility can introduce interventions to mitigate further declines. 

Staff participation is a key component of a successful QAPI program. Look for ways to involve staff members at every step of the process. 

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

Over the course of nine years, researchers looked at how often people worked shifts, the type of shift they worked, and how many years they worked shifts. They found a higher risk of depression and anxiety was positively associated with shift frequency. They did not find a difference in risk whether the person worked nights or days. 

Results in JAMA Network Open also suggested the associations of shift work with anxiety and depression may be partly explained by smoking, sleep duration and  body mass index (BMI). Those factors made up 31% of the link between shift work and depression and 21% of the association between shift work and anxiety.

The research involved an analysis of data from 87 nursing homes, including administrative data for 10,000 residents and survey data for 3,500 nursing assistants. Results showed residents on care units with higher best practice use among CNAs had 32% higher odds of reporting mild pain compared with residents on care units with lower levels of best practice use among nursing assistants.

Best practices include CNAs recognizing verbal and nonverbal signs of possible pain among residents, and then reporting this new or worsened pain to their supervisors (usually nurses). Researchers said earlier pain recognition and reporting by aides could lead to better assessment and pain management by licensed clinicians.

“Nursing assistants are rarely involved in guideline development and quality improvement programs or offered continuing education about pain management,” the study’s authors wrote. “Their important role at the forefront of pain detection should be acknowledged and their capacity better optimized, for example, through more attention to this pivotal workforce with respect to both basic and ongoing education.” 

The study appeared in the Journal of the American Geriatrics Society. 

Despite these gains in usage, however, telehealth visits within long-term care remain underutilized generally, and could use some additional support, experts said.

Researchers from several Boston universities and medical centers found that from January 2019 to February 2020, telemedicine visits accounted for less than 1% of all health visits for nursing home residents. That number increased to 15% of routine SNF visits and 37% of other outpatient visits in SNFs in early 2020, before dropping again and stabilizing at 2% of routine SNF encounters by mid-2021. Half of all telemedicine visits in 2020 and 2021 were clustered in 18% of nursing facilities. 

In 2019, just three Midwestern states — where a lack of local specialists created high need — had more than 1% of health visits delivered via technology. A year later, all US states were using telemedicine at higher levels. But by the first half of 2022, just one state used telemedicine for more than 10% of nursing facility visits and eight states had  returned to using it less than 1% of the time. 

“Our results should be a wake-up call that telemedicine has not been a ‘field of dreams’ situation where SNFs just come and use the technology without any further systems in place,” said study author Michael L. Barnett, MD, associate professor of Health Policy and Management at Harvard T. H. Chan School of Public Health.

The study showed more LTC residents are using telemedicine for psychiatry visits than ever before, and that it improved access. Older adults remain the least likely group to seek mental health assistance overall: Just 9% of seniors seek mental health treatment, previous studies have shown.

“A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures,” the researchers wrote in JAMA Network Open.