ADMINISTRATOR IN TRAINING MANUAL
NURSING DEPARTMENT
Module 6
Stan Mucinic, LNHA
NURSING DEPARTMENT - AIT TASK LIST
1. The nursing department comprises 80% of your staff.
2. The director of nursing is a department head like all of your other department heads but your relationship with the DON is critical to the smooth operation of the facility and in establishing an efficient nursing program and high quality care.
3. If you are experiencing personality conflicts with your DON, then this is a very serious issue.
4. The DON is responsible to manage the nursing program, the medical director is responsible to manage the medical program and you are responsible to ensure that the facility is compliance with all laws and regulations and that everyone is doing their job.
5. The licensed nurses are educated and experienced health care professionals who have to abide by the state nurse practice act and must abide by their professional standards of care.
6. When acuity levels are high, and the facility is experiencing a high number of admissions and discharges, and in their professional opinion, the minimum state staffing levels are not sufficient to provide needed care, they will voice their concerns.
7. You may have a situation where nurses may threaten to walk out unless they receive more support to meet current needs.
8. These are difficult situations to handle. State nursing staffing requirements for licensed nurses and nurse aides are minimal staffing levels. A facility is required to assess the patient load and acuity needs of their residents and staff according.
9. For instance if you have a wing with 10 patients who have had a tracheotomy and need suctioning and tube feedings, that is a high acuity and those nurses may not have the time to handle the needs of other patients.
10. Check the last survey to see what tags the nursing department received
11. Review the plan of correction to see if the facility is in compliance with the plan
12. Does the facility have an assistant director of nursing? Iif 121 beds or more the facility is required to have an ADON.
13. Does the facility have a full time staff development coordinator?
14. If not, then who handles nursing continuing education and tracks required immunizations and certification requirements of nursing aides?
15. Who is designated to coordinate incident reports and adverse incident reporting?
16. Ask to see the adverse incident log and how the department tracks the 1, 5 and 15 day state and federal reports when there is an adverse or serious incident involving injury to a resident
17. Ask to see review the nursing staffing plan for the month
18. Does the facility have a full time staffing coordinating?
19. Is the facility keeping to its maximum staffing hours and budget?
20. Are staff constantly calling off or staff not clocking in and out for lunch or at the end of their shift?
21. Is the facility experiencing a high rate of overtime?
22. What is the staffing PPD for nurses and for nursing aides?
23. Was the department within budgeted hours and dollars per the budget plan last month.
24. Is the facility within budget for labor hours this week?
25. What does the department do if a nurse or nurse aide fails to clock in properly or has a pattern of failing to clock in and clock out on time?
26. What is the facility policy regarding the timeframe nursing staff must call if they cannot work their shift (many companies require at least 2 hours advance notice so the facility can find a replacement. The replacement will most likely involve having someone on the current working shift to work a second shift.
27. Who checks the report of payroll checks paid out against the list of active employee to make sure that no one is being paid a paycheck who is not on the schedule or the payroll. Sometimes phantom employees can appear on the payroll list and this is an employee that was created by someone and who is collecting their paychecks. You must prepare for the worst and hope for the best, but unless someone is checking and has controls in place, the incentive is there to embezzle money from a facility. It happens and if you cannot make the argument that you were diligent and tool reasonable measures to detect such practices, you will lose your job as well. I have seen it before.
28. Does the facility use agency or temporary nurses and nursing aides? If so, how often and how much is it costing above the budgeted amount
29. Observe how the staffing coordinator calculates necessary nursing hours and how many changes she has to make to replace staff, add staff or reduce staff based on census
30. Since nursing is 80 percent of your total payroll cost, and rarely does your staffing schedule survive the first day of the week, how your nursing staff handles call offs and missed punches can and does have a huge impact on your operating financial results. The staffing coordinator and DON, ADON and charge nurses must work together to control staffing and staffing costs
31. See how much time it takes for the nursing department to check the Kronos (daily time records) which records the hours clocked by staff and check those hours against the staffing roster to make sure that everyone is accounted for and to ensure that the facility met minimum state staffing requirements. In many states there are stiff penalties for missing minimum hours.
32. It may take most of the morning or afternoon to reconcile those records. This is a lot of time consumed by the DON, staffing coordinator, accounts payable clerk and nursing staff.
33. UNIT CLERK - Ask them what they do to make sure that telephone orders from physicians, lab reports and other key communications are accounted for and followed up by staff
34. Nursing staff must call and notify the attending physician of all test results received by the facility.
35. Review a resident chart and see how the chart is divided into various sections, review the progress notes in the chart and the other information in the chart.
36. Locate the MAR (medication administration record) and the TAR (treatment administration record)
37. Check to make sure that there are no holes in the MAR and TAR – where a nurse failed initial administration of drug or failed to record it in the MAR.
38. If something is not recorded or documented, then it did not happen
39. Review the 24 hour nursing report that records major incidents and admissions and discharges. Is the information in the reports accurate?
40. Does the 24 hour report include all the information for individuals admitted or discharged, including time of admission, name and room number.
41. Time of admission or discharge is Critical!!!!. If they were discharged or admitted before midnight, then you do not get paid for the day and cannot bill. But if they were admitted or discharged after midnight then you get paid. If they were transferred at 12:01 AM to the hospital, the resident appears on your census. If they went out at 11:59 PM, the resident appears on the hospital census.
42. Is the census count accurate? The nurses are required to count the heads in the beds and record all discharges and admissions. But often they omit to record both. And that can cause tremendous problems because you will be billing for people not there or not billing for people who are.
43. Observe the stand up meeting and see how staff reconciles the census
44. Talk to the medical supplies clerk and see how she orders supplies and how often.
45. Ask what the budget is for each medical supply item? Briefs, soap, shampoo, toothpaste, combs, emesis basins, bed pans, stock drugs, gels, supplements, etc.
46. Is the medical supplies clerk keeping within the budget? Or is she going over. Ask to order supplies and then stock the supplies once received.
47. Are any supplies stored directly on the floor?
48. Who has access to the store room? Who has keys?
49. Are the older items ordered used first or are the newer supplies used first?
50. Does the staff run short of supplies during shifts because they have trouble getting access to supplies or the supplies they need were not ordered and stocked.
51. Ask who reviews the pharmacy bill to make sure it is accurate and identify brand name drugs that can be replaced with generic brands at a fraction of the cost.
52. Who checks to see that the facility receives a credit for overcharges each month which can be thousands of dollars each month?
53. Identify costly drugs being ordered and the exact amount of those drugs.
54. Share that information with the admissions folks so they can be aware of what to look for when assessing a new admission.
55. That drug price list will be invaluable when assessing new admissions.
56. One resident with expensive antibiotics can put you into a financial loss for the month until discharged
57. You must know what it will costs to treat a resident for the various medical conditions
58. Does the DON review each prospective admission to ensure the facility can meet their needs and cost out the care?
59. Does therapy review each referral to assess the potential RUG rate you will get and if there are other referrals that offer more reimbursement
60. Check the medication rooms and see if they are clean and organized. Are any supplies stored directly on the floor?
61. Check the resident/staff refrigerator for expired food items or items with no name or date.
62. Resident and staff bathroom must have a “WASH HANDS SIGN”.
63. Are their any expired meds or supplies that have expiration dates? They must not be in the medication room. If found by surveyors, you will be cited in a survey
64. Is the temperature log for the med refrigerator filled out properly on each shift? Is there a thermometer in the refrigerator? Is it in the front part of the refrigerator? Check the actual temperatures gauges. Are they any temps recorded above the maximum temp? Was maintenance notified and the refrigerator fixed?
65. Check that the medication refrigerator is it locked.
66. Check the medication carts. Are they clean. Are they locked. Ask to look inside. Are they any expired drugs or alcohol or other open items need to be dated
67. Check that residents have a wrist band with their name on it, if facility policy.
68. Check to see if the resident chart has a photo of each resident in the chart – to identify for medication administration. New nurse or temp nurse will not know your residents
69. Check resident wheel chairs and if the wheels or the chair or caked in dirt or are they clean and in good working order? Do the wheels squeak or squeal?
70. Do residents have problems moving their wheel chair? Do the wheels turn smoothly without extra exertion? Is the resident able to operate the chair?
71. Do the foot rests fit or match the chair? (this is a dignity issue)
72. Do residents have a good seat cushion for their wheelchair.. Critical to avoid pressure sores
73. Sit on the cushions and feel if it soft and comfortable.
74. Residents sit in those chairs up to 12 hours per day
75. Inspect the emergency medication kit.
76. Is there a list of the contents on the outside of the kit? Is the kit sealed? Is there documentation of any meds being removed from the kit and administered.
77. What types of meds are in the kit? Ask nursing staff when nurses would use meds from the E-kit.
78. Observe to see if nursing staff knock on doors before entering.
79. Observe how staff interact with residents and family members.
80. How does staff handle residents who are behavior problems or acting act or are demented.
81. Are they able to remain calm and handle the situation appropriately or do they seem at a loss for what to do
82. Ask nursing staff what kind of in-services they receive on how to handle residents with dementia and behavioral issues.
83. Check the grievance log and see if there any complaints concerning the nursing department and the care being provided
84. Talk to residents and family members and ask them how things are going? Ask them how they are doing? Ask them how they like their stay at the facility and if they have any concerns.
85. It is important to remember that people who feel you care about them are less likely to file a complaint against you or sue you. It is critically important to have a positive relationship with residents and family member as well as with staff.