You Are Here:Home/Resources/DNS Navigator/DNS Navigator Details
Almost 200 years ago, physicians discovered that deadly pathogens were transmitted from patient to patient via the hands of nurses and physicians, and that washing hands between appointments with patients would dramatically reduce the mortality rate (World Health Organization, 2009). While tremendous strides in hand hygiene compliance have been made since the 19th century, there is still room for improvement—as the Centers for Medicare & Medicaid Services (CMS) noted during its Call with Nursing Homes on May 13, 2020 (CMS, 2020). The CMS Northeast Division Director for Survey and Reinforcement named three areas of practice that surveyors have noted need improvement, and hand hygiene was at the top of the list.
Factors Affecting Compliance with Hand Hygiene
Properly washing hands and performing hand hygiene is an essential skill every healthcare worker (HCW) must possess. The AAPACN Hand Hygiene Competency Tool can assist nurse leaders documenting achievement of competence with this skill. However, competence does not necessarily translate into compliance.
A systematic review of the research studying hand hygiene of HCW in the hospital setting found several factors affect compliance (Erasmus, et. al, 2010). While the nursing home setting is unique and poses different challenges from the acute care setting, the findings from this study can enlighten the Infection Preventionist (IP) and other nurse leaders as to factors they may consider when working toward improving hand hygiene compliance in the nursing home. See the table below for some helpful factors to consider.
The Centers for Medicare and Medicaid Services (CMS) has tried to make it easier for dialysis providers to offer home dialysis to long-term care residents to reduce the risks of COVID-19 transmission. Note: For more information, see Quality, Safety, and Oversight (QSO) memo QSO-20-19-ESRD – REVISED, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Dialysis Facilities, as well as the Expanding Availability of Renal Dialysis Services to ESRD Patients section of COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.
However, home dialysis often isn’t a realistic option, says Mary Gruel, RN, CDN, education coordinator at Tri State Dialysis in Dubuque, IA, and program coordinator for the April 2020 Spring Clinical Meetings’ nursing track at the National Kidney Foundation. “During the pandemic is not the time to change modalities to home therapy,” she advises. “Most dialysis facilities don’t have the training and staffing capacity to make that transition for multiple residents or the extra machines that would be needed to provide that service in the facility.”
Consequently, many nursing homes will need to continue to send residents out for dialysis treatments for the duration of the pandemic. However, taking the following steps can help mitigate the risks:
Assess whether you should cohort dialysis residents
In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.
“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”
While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”
Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”
The Centers for Medicare & Medicaid Services (CMS) makes clear that nursing homes should have a sexual expression/intimacy program that supports sexually intimate relationships when possible. Specifically, F607 (Develop/Implement Abuse/Neglect, etc. Policies) in Appendix PP of the State Operations Manual states:
The facility must have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves (but is not limited to):
Here are critical steps for establishing a viable sexual expression/intimacy program for residents:
Once providers conceptually understand trauma-informed care, they often get stuck navigating what to do next. Steps that can help directors of nursing services (DNSs) and other members of the management team begin to operationalize trauma-informed care include the following:
Avoid a checklist mentality
“It sounds cliché, but trauma-informed care is a process, not a destination,” says Kathleen Weissberg, OTD, OTR/L, CMDCP, education director at Select Rehabilitation in Glenview, IL. “Every time I teach, I’m asked, ‘Where is my checklist? How can I make sure we are doing everything that we are supposed to do?’”
To access this resource, please login or sign up for a membership.