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According to the Centers for Disease Control and Prevention (CDC), the elderly are the population most vulnerable to the effects of COVID-19, and the risk of illness severity increases with age. Other conditions—including diabetes mellitus, chronic kidney disease, neurological conditions such as dementia, cancer, cardiovascular disease, and obesity—also increase the risk for a severe case of COVID-19. Because those living in skilled nursing facilities (SNFs) generally are those with advanced age, comorbidities, or both, SNFs are on the forefront of battling this virus. Adding to the complexity of this fight, a recent paper by Perrotta et al., “COVID-19 and the Elderly: Insights into Pathogenesis and Clinical Decision-Making” reports that elderly patients with COVID-19 may present with atypical symptoms. This article explores how the nurse leader can help nurses gain the competencies necessary to care for residents who exhibit symptoms of potential COVID-19.
F726 Nursing Services
F-tag F726, Nursing Services, requires the following:
§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.
§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. (emphasis added)
Nursing home staff sometimes crush medications that should not be crushed, says Diane Crutchfield, PharmD, BCGP, an independent consultant pharmacist in Knoxville, TN. “Staff crush medications to make them easier—or in some cases even possible—to administer. For example, some residents will spit out tablets or capsules even if they are in a spoonful of applesauce; other residents may have trouble swallowing due to a history of stroke. As a result, staff try to crush medications as much as possible. Unfortunately, when staff are trying to give medications to, for example, 20 residents who may have seven or eight medications each, they may not take the time to stop and see whether each medication can be crushed.”
Steps that directors of nursing services (DNSs) can implement to ensure staff are on the right track when it comes to crushing medications include the following:
Provide reference materials
“The most critical best practice is knowing which medications cannot be crushed based on the manufacturer’s instructions,” says Dana Kelleher, RPh, an independent consultant pharmacist based in Coopersburg, PA. “Most of the time, staff shouldn’t crush any medication that a manufacturer says ‘do not crush.’”
Either the pharmacy labeling or the electronic medication administration record (MAR) should say, “Do not crush this medication,” if applicable, points out Crutchfield. The guidance for surveyors in F761 (Label/Store Drugs & Biologicals) in Appendix PP of the State Operations Manual addresses a nursing home’s responsibility to comply “with currently accepted labeling requirements, even though the pharmacies are responsible for the actual labeling”:
Personal protective equipment (PPE) is currently a topic of discussion on a global level. The COVID-19 pandemic has brought infection control procedures and the use of PPE under intense scrutiny, especially in long-term care. On a daily basis, we hear about the shortcomings of PPE supply and use, along with the lack of proper infection control in healthcare. Do not let the negative publicity paralyze you. As a leader, it is imperative to analyze what occurs in the facility and find ways to improve. By investigating competency and compliance, directors of nursing or other nurse leaders, such as infection preventionists, can improve PPE utilization in their facilities.
History of PPE
Since Leonardo DaVinci invented the first respirator to prevent contamination from chemical warfare in the 16th century, healthcare personnel (HCP) have been attempting to protect themselves from illness (Segal, 2016). As understanding of pathogens increased, PPE have evolved in response. PPE as we know it today originated in the 1970s when the Centers for Disease Control and Prevention (CDC) published the manual Isolation Techniques for Use in Hospitals. In the 1980s, PPE use intensified due to the human immunodeficiency virus (HIV) pathogen, which led to universal precautions being introduced in 1985 to prevent the transmission of infection. In addition to the gowns and gloves already being utilized, facemasks and eye shields were implemented to protect mucous membranes. In 1989, the Occupational Safety and Health Administration (OSHA) proposed a rule on occupational exposure to bloodborne pathogens. The rule on bloodborne pathogens was then finalized and published in 1991. The CDC issued an isolation guideline in 2007 which addressed PPE, including the donning and doffing procedures (Segal, 2016).
Transmission-Based Precautions and PPE
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 & Medicaid Services (CMS) most likely will specify education and training requirements for trauma-informed care under F741 (sufficient/competent staff‐behavioral health needs) and/or F949 (behavioral health training) in the upcoming revised Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” in the State Operations Manual—a revision that is now expected to be released in the second quarter of calendar year 2020, according to Quality, Safety, and Oversight (QSO) memo QSO-20-03-NH.
When they arrive, those requirements may not be too onerous because many staff members already should have skills that will translate across to trauma-informed care, such as knowing how to de-escalate and how to work with residents who have memory impairments, says Jill Schumann, MBA, president and CEO of LeadingAge Maryland in Baltimore and co-author of the Foundations of Trauma-Informed Care Toolkit and Implementing Trauma-Informed Care: A Guidebook.
Regardless of the exact requirements that CMS deems necessary, focusing on the following elements will help directors of nursing services (DNSs) and other members of the management team to implement effective trauma-informed care:
The July 2019 Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency Proposed Rule would give Medicare- and Medicaid-certified nursing homes a break by postponing the Requirements of Participation’s Phase 3 rollout of the training requirements at §483.95(d) in the Code of Federal Regulations (CFR), which is F944 (QAPI Training), as well as §483.95(f)(1) and (2), which is F946 (Compliance and Ethics Training). However, this November 28, providers still must have staff training in place to meet multiple new F-tag requirements under CFR §483.95 (Training Requirements):
F940 (Training Requirements – General);
F941 (Communication Training);
F942 (Resident’s Rights Training);
F945 (Infection Control Training);
F947 (Required Inservice Training for Nurse Aides). Note: While most of F947 has already been implemented, the component related to §483.95(g)(3) will implement in Phase 3. This requires that inservice training for nurse aides “address areas of weakness as determined in nurse aides' performance reviews and facility assessment at §483.70(e) and may address the special needs of residents as determined by the facility staff”; and
F949 (Behavioral Health Training).
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