Nurses have often heard “if it wasn’t documented, it wasn’t done,” but they still struggle to consistently capture documentation that is timely, accurate, and comprehensive. This struggle sometimes emerges when underlying system failures go unaddressed by leadership. To fix this, the director of nursing services (DNS) and other nurse leaders need to improve the processes that are interfering with sound documentation practices and provide education that links a nurse’s skills to the documentation.

To accomplish these goals, the American Association of Directors of Nursing Services (AADNS) recently published the Documentation Toolkit for the Nurse Leader, which contains several helpful tools and resources to make lasting improvements to nursing documentation. Alexis Roam, MSN, RN-BC, DNS-CT, QCP, curriculum development specialist for AADNS, shares some tips for how DNSs and other nurse leaders can use this tool to review their processes and overcome documentation pitfalls.

As the COVID-19 pandemic continues to pick up speed in many states without waiting for a fall/winter surge, nursing homes across the country are looking for ways to streamline and improve systems so that they can provide high-quality, patient-centered care that also prioritizes infection prevention and control. “One way to achieve this goal is to have open conversations about what is important to residents and families with regard to medications—and also be mindful of the time and infection control burdens that medication management can impose on overstretched, overstressed staff,” suggests Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, executive director of The Peter Lamy Center on Drug Therapy and Aging and professor of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore.

Working with the U.S. Deprescribing Research Network, The Peter Lamy Center pulled together a multidisciplinary task force, co-chaired by Brandt, that developed Optimizing Medication Management During the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care to provide a framework of guiding principles for this conversation.

“The goal of the guide is patient-centered—to improve outcomes for older adults living in post-acute and long-term care facilities,” says Michael Steinman, MD, professor of Medicine with a focus in geriatrics at the University of California – San Francisco and the San Francisco VA Medical Center, and co-principal investigator at the U.S. Deprescribing Research Network. Steinman also co-chaired the multidisciplinary task force that created the guide. “The task force wanted to make the guide as useful as possible in improving those outcomes while still recognizing that healthcare providers and staff are incredibly busy during this time of the pandemic.”

Medication changes should be able to help nursing homes in three key ways:

The FY 2021 SNF PPS Proposed Rule was a shadow of what the Centers for Medicare & Medicaid Services (CMS) had planned due to the ongoing coronavirus 2019 (COVID-19) public health emergency. So it's no surprise that the final rule, Medicare Program: Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities (SNFs); Updates to the Value-Based Purchasing Program for Federal Fiscal Year (FY) 2021 (CMS-1737-F), finalizes most, if not quite all, of the proposals without modification. And while COVID-19 caused some changes to the payment rate calculations, CMS cited commenters' requests for additional relief from COVID-19 as beyond the scope of this rulemaking. 

Here are some of the key updates that directors of nursing services (DNSs) should pay attention to:

The COVID-19 pandemic is a strange and difficult time for long-term care residents. There is a lot happening in their environment that is unfamiliar, and nurse leaders have the difficult job of ensuring residents’ physical safety while also addressing the importance of combating resident loneliness. Leaders have to adapt, be strategic, and find clever ways to engage residents. Joan Devine, RN, director of education for Pioneer Network, offers some insights, resources, and ideas that nurse leaders can utilize to improve person-centered care and resident well-being during this time.

Editor’s note: This is the third article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes. Find the first article explaining the basics of what it is and why it matters here and the second article explaining how to use advance care planning for maximum effectiveness in providing person-centered care here.

Advance care planning involves more than completing documents, such as advance directives and POLST (Physician Orders for Life-Sustaining Treatment) forms, says Shigeko (Seiko) Izumi, PhD, RN, FPCN, associate professor in the School of Nursing at Oregon Health & Science University in Portland, OR; presenter of the April 22 webinar “COVID Conversations: Team Approach To Assisting Patients With Advance Care Planning” from the Coalition for Compassionate Care of California; and co-author of “A Model to Promote Clinicians' Understanding of the Continuum of Advance Care Planning” in the Journal of Palliative Medicine (2017; 20(3):220-22). 

“It’s a mistake to fixate on the paper documents. Without conversation, the documents alone don’t help much because they can be overlooked in times of crisis,” stresses Izumi. “The most important part of advance care planning is having the conversation to learn the resident’s values, goals, and treatment preferences—and making sure the people around that resident also know what is important to them so that even without documentation, they can advocate for the resident when the resident cannot express their own wishes.” 

Skilled nursing facilities (SNFs) are collecting a tremendous amount of data in response to the COVID-19 pandemic. When this data is translated into information, it becomes a powerful tool to evaluate performance, identify potential gaps in processes, and assist with root cause analyses, with the end result of decreasing the risk of exposure to COVID-19 in the facility. However, the sheer volume of data can be difficult to parse; numbers that become overwhelming or lack meaning are not helpful. This article will suggest methods to translate into more useful forms the data that SNFs collect as part of the requirements found in the State Operations Manual, in Appendix PP, under F880 (Infection Control) for process and outcome surveillance, as well what is required to be reported to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) COVID-19 Module for LTCFs database. By doing this, the SNF can prepare for a first outbreak or a potential second wave in their facility or local community.

In Appendix PP of the State Operations Manual, under F880, the guidance informs surveyors and providers that process and outcome surveillance should be established and is a necessary component to the IPCP. Note that some of the surveillance data the SNF collects as part of the IPCP must be reported to the NHSN database, COVID-19 Module for LTCFs, while other data is optional to report.