Thunderhawk Policy and Procedure Manual · Thunderhawk Management & Consulting, LLC page 1...
Transcript of Thunderhawk Policy and Procedure Manual · Thunderhawk Management & Consulting, LLC page 1...
Thunderhawk Management & Consulting, LLC page 1
Thunderhawk Policy and
Procedure Manual
When using this manual, please consider the following important points:
1. The policies and procedures outlined in the manual will never supersede
current regulation. To the best of our knowledge, these guidelines reflect
current regulation; nevertheless, they cannot be considered universal
recommendations. For individual application, all recommendations must
be considered in light of the resident’s condition. The authors and
publishers disclaim responsibility for any adverse effects resulting directly
or indirectly from the suggested procedures, from any undetected errors,
or from the reader’s misunderstanding of the text or video content.
2. Regulations and interpretations will change and it is your responsibility to
ensure that the Vantage Pointe Village or residential care community is
operated under the guidelines outlined in current regulation. Review
regulations, policy, procedures and instructions to ensure compatibility
with the regulations your community is obligated to abide by.
3. The guidelines outlined in this manual will never supersede a state
regulatory agency’s directive, physician order, or direction from a licensed
medical professional.
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4. Hands-on resident care of any kind should always be in accordance with
physician orders. The interventions in this manual are not intended to be
personalized plans of care.
Copyright © 2009 by Thunderhawk Management & Consulting, LLC
All rights reserved. Permission is granted to photocopy written materials,
certificates and quizzes for internal use within the purchasing organization.
Otherwise this publication may not be reproduced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without prior written permission from the publisher.
Table of Contents
General Policies ............................................................................... 8 Personal Property/Theft and Loss............................................................................................... 9
Abuse, Fraud, and Wrongdoing ................................................................................................ 12
Personal Care Attendants ......................................................................................................... 14
Home Health Agencies ............................................................................................................. 15
Motorized Mobility Devices ....................................................................................................... 16
Resident Transportation........................................................................................................... 17
Resident Independent Departure Assessment ...................................................................... 18
Sign-In/Sign-Out....................................................................................................................... 19
Firearms................................................................................................................................... 20
Personal Rights ........................................................................................................................ 21
Dignity...................................................................................................................................... 23
Corporal Punishment and Restraints ........................................................................................ 24
Complaints................................................................................................................................ 25
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Staffing ........................................................................................... 26 Staffing Introduction .................................................................................................................. 27
Staff Training ............................................................................................................................ 28
Job Description: Executive Director........................................................................................ 30
Job Description: Assistant Executive Director............................................................................ 31
Job Description: Resident Care Coordinator ............................................................................ 33
Job Description: Medication Aide .............................................................................................. 35
Job
Personal Assistant…………………………………………………………………………………37
Volunteers........................................................................................................................... 39
Admissions and Move-In.............................................................. 41 Resident Pre-Admission Appraisal ........................................................................................... 42
Allowable Health Conditions..................................................................................................... 44
Day of Admission/Move-In........................................................................................................ 46
Change in Condition................................................................................................................. 47
Ongoing Resident Appraisals.................................................................................................. 50
Activity Assessments ............................................................................................................... 52
Admission Agreements ............................................................................................................ 53
Service Plans ........................................................................................................................... 54
Resident Care Conference ...................................................................................................... 56
Move-Out .................................................................................................................................. 59
Resident Care ................................................................................. 60 Basic Care Services .................................................................................................................. 61
Use of Assistive Devices and Ambulatory Aids ........................................................................ 64
Hygiene and Grooming ............................................................................................................. 65
Dressing ................................................................................................................................... 66
Sleep and Rest ......................................................................................................................... 67
Incontinence............................................................................................................................. 69
Nutrition and Weights ................................................................................................................ 71
Podiatry and Nail Care.............................................................................................................. 72
Personal Assistant Daily Schedule ........................................................................................... 73
Sexual Expression.................................................................................................................... 77
Medication Management ............................................................... 78 Medication Storage ................................................................................................................... 79
Medication Records .................................................................................................................. 80
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Telephone Orders ..................................................................................................................... 81
Medication Labels ..................................................................................................................... 82
Resident Arrives with a Medication ........................................................................................... 83
Medication Refills ..................................................................................................................... 84
Medications are Permanently Discontinued .............................................................................. 85
Hold Orders .............................................................................................................................. 86
Expired Medications................................................................................................................. 87
Medications Left Behind by a Resident ..................................................................................... 88
Medication Refusal and/or Missed Doses ................................................................................. 89
Crushing Medications ............................................................................................................... 90
Transferring Medications for Home Visits and Outings ............................................................. 91
Sample Medications ................................................................................................................. 92
Use of Emergency Medications ................................................................................................ 93
Injections .................................................................................................................................. 94
Over-the-Counter (OTC) Medications ....................................................................................... 96
Psychotropic Medications ......................................................................................................... 97 Warfarin and Other Anticoagulants ........................................................................................... 98
Narcotics, Controlled Substances, and Preventing Drug Diversion ........................................ 99
Emergencies and Medical Needs ................................................
101 Physician and Other Medical Appointments ........................................................................... 102
Labs and Outside Medical Services ........................................................................................ 103
Licensure of Nursing Personnel .............................................................................................. 104
Medical Emergencies ............................................................................................................. 105
Psychiatric Emergencies........................................................................................................ 108
Falls ........................................................................................................................................ 109
Death of a Resident ................................................................................................................ 110
Elopement/Missing Resident.................................................................................................. 112
Advance Directives................................................................................................................. 115
Documentation and Forms........................................................ 117 Confidentiality ......................................................................................................................... 118
Narrative Charting Entries ....................................................................................................... 119
Incident Reports ..................................................................................................................... 120
Procedure ............................................................................................................................... 120
Abbreviations .......................................................................................................................... 121
Approved Abbreviations ......................................................................................................... 122
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Terminology
Various terms related to resident care are used throughout this manual. While
most of these terms are commonly accepted in the industry, there is some
variation from state to state, and within different organizations. To clarify these
terms and to improve your understanding of how they are used in this manual, a
brief explanation is provided below:
Executive Director
This is the person responsible for the day-to-day operations of
Vantage Pointe Village or residential care community. Some
state regulations specify other terms for this individual, such as
manager, and many organizations will refer to this person as the
"Executive Director."
Community
The care setting is referred to as a Vantage Pointe Village or residential care community. Although the term "facility" is often used in state regulations and by some in the industry, we feel it is important to distinguish a Vantage Pointe Village or residential care residence as a home, rather than strictly a clinical facility.
When the word "community" is used in this manual it is referring
to the care setting, not the community at large. Clarification will
be provided if necessary. In some cases, such as when quoting
from regulations, the term facility will be used.
Personal
Assistant
This is the person providing care. Although there are
exceptions, typically this person is not a licensed medical
professional.
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Designated Many of the policies in this manual will refer to the "designated
Representative representative." It is recommended that you replace this title
with the specific title of the individual(s) within your community
that are responsible for the policy or procedure being described.
Licensee
This is the person or organization that has obtained a license to
operate the Vantage Pointe Village or residential care
community from the appropriate state agency. In some cases
the Executive Director and licensee is the same person.
Nurses
Some policies and procedures in this manual refer to a nurse, if
your community does not utilize nurses, modify the policies and
procedures accordingly.
Physician
Many policies in this manual recommend obtaining a "physician
order" or prescription. In many states and situations the order or
prescription can also be written by a Nurse Practitioner (NP) or
Physician's Assistant (PA).
Resident
The resident is the individual receiving care. In other healthcare
settings the term "patient" or "client" are more common, but to
foster a homelike atmosphere the term resident is used in the
Vantage Pointe Village and residential care industries.
Responsible
Party
Most residents living in Vantage Pointe Village or residential
care communities will have a responsible party. This may be a
family member with power of attorney, conservator, or another
individual or agency that is legally authorized to make decisions
on behalf of the resident.
GENERAL POLICIES
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
General Policies
GENERAL POLICIES
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POLICY: Personal Property/Theft and Loss
This Theft and Loss Policy and Procedure program will be reviewed twice a year
by all staff.
Personal Property
1. General
a. Residents will be encouraged to keep no more than $50.00 cash at
any time.
b. Residents will be requested to keep fine jewelry and other items of
value in a safe deposit box at their banking institution.
c. No items of value will be entrusted to the community for safe
keeping and no cash or other moneys will be entrusted to the
community.
d. The community does not have a safe on the premises to allow for
safe keeping of residents’ valuables. Residents are encouraged to
use their own private banking institution to provide this service.
The community provides all rooms with either a lockable door to
which the resident has a key, and/or a lockable cabinet to which the
resident has a key.
2. Inventory
a. The community maintains a current inventory of all personal
property identified by residents, unless the resident is able to
secure his/her room or refuses the inventory and the refusal is
documented.
b. When the inventory is complete, copies will be distributed to and
kept by the community, the resident, and the resident’s responsible
party.
c. The resident and responsible party are asked to notify the
community of any additions to, or removal of, personal property
inventory. The community will document appropriately.
d. In the event of a resident’s discharge or a resident’s death, the
inventory list will be verified and the personal items will be packed.
When the items are returned to the resident’s responsible party the
list will be re-verified and signed in receipt of belongings.
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3. Identification
a. Upon admission, all residents will be requested to appropriately
label all clothing and personal items.
b. All clothing will be labeled in an inconspicuous area (such as the
clothing tag) with permanent laundry markers to clearly identify
which resident they belong to.
c. All personal belongings that can be marked with permanent pen will
be marked in discreet locations.
d. In cases where the item or items cannot be safely labeled with a
non-erasable marker an electric pencil will be used to engrave the
resident’s name in a discreet place on the items, if the resident
agrees.
Theft and Loss
1. The community documents and appropriately investigates all alleged and
actual theft and loss of personal property.
2. Residents are encouraged to notify staff immediately if they notice a
personal item is missing.
a. Staff will conduct a thorough search for the missing item(s).
b. If the personal belongings cannot be found, an estimate of their
value will be assessed. The estimate will be the original purchase
price plus or minus any appreciation or depreciation that has
occurred.
c. If the theft exceeds $100.00 or more, a report shall be filed with the
appropriate local law enforcement agency.
d. All appropriate documentation of the incident will be given to the
responsible parties.
i. The community will maintain the records on file for a
minimum of three (3) years after the theft.
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Notification
1. The community notified all appropriate parties about the theft and loss
prevention program and provides them with copies of applicable laws.
2. The community posts the policy and procedures for safeguarding the
residents’ property in a common area accessible to all residents and
visitors.
3. Upon moving into the community, the resident and appropriate parties will
be notified verbally and given a copy of the theft and loss policy.
4. Copies of these procedures and applicable laws are available to anyone
upon request.
GENERAL POLICIES
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POLICY: Abuse, Fraud, and Wrongdoing
The community takes all reasonable steps to prevent resident abuse and
neglect.
Residents, their responsible parties, personnel, health professionals and all
relevant stakeholders are encouraged to report in good faith any activity, policy
or practice, fraud, abuse and any other wrongdoing that he/she believes violates
professional standards of practice or is against the law, or poses a substantial
risk to the health, safety, welfare or rights of a resident.
Residents, their responsible parties, personnel, health professionals and all
relevant stakeholders may report such activities, policies or practices without fear
of restraint, interference, coercion, discrimination or reprisal. Reasonable efforts
are made to maintain the confidentiality of the resident, their family, personnel,
healthcare professional or relevant stakeholders.
The Executive Director will investigate any reports of abuse, fraud, or other
wrongdoing.
Procedure
1. All staff will receive training on elder abuse incidence, signs and
symptoms, and reporting requirements.
2. Residents, their responsible parties, personnel, health professionals and
all relevant stakeholders are encouraged to report any suspected
incidence of abuse, fraud, or other wrongdoing.
3. If a report of abuse, fraud, or other wrongdoing is received:
a. The Executive Director is notified immediately
b. Any urgent medical or safety issues are addressed immediately.
c. The Executive Director or other designated representative initiates
and investigation.
d. The resident's responsible party is notified.
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4. If the suspected abuse, fraud, or other wrongdoing is substantiated a
written report is made to the appropriate licensing/regulatory agency, the
responsible party, the Ombudsman, and Adult Protective Services.
5. All appropriate parties are notified of the outcome of the investigation.
6. Appropriate disciplinary actions will be made if community staff
participated in substantiated abuse, fraud, or other wrongdoing.
GENERAL POLICIES
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POLICY: Personal Care Attendants
Residents who desire to use a personal care attendant for extended periods of
time may do so with the prior approval of the Executive Director.
Procedure
1. Resident needs may require a personal attendant, but must not require 24
hour skilled nursing care.
2. Personal Care Attendants from outside agencies may be used if approved
by the Executive Director. The agency shall ensure a criminal clearance
on all staff, health screening, appropriate insurance including liability and
worker’s compensation, proof of appropriate employer tax obligations,
including but not limited to withholding of state and federal taxes, payment
of disability and unemployment insurance. All appropriate labor laws are
to be followed and the Personal Care Attendant supervised by an agency
Executive Director familiar with this Vantage Pointe Village community
operations.
3. All Personal Care Attendants from outside agencies are to be fully trained
in all necessary care giving skills by the agency prior to coming in the
Vantage Pointe Village community to serve a resident.
4. Personal Care Attendants may not perform any act not allowed by
regulation or law.
5. The Personal Care Attendant, if employed by an agency, is expected to
notify his/her supervisor and community staff of any change in resident
status.
6. The Personal Care Attendants, if employed by an agency, are not to
provide care at any time to any other resident in the community.
7. It is the responsibility of the agency to ensure proper training of the
Personal Care Attendant employed by the agency in emergency
procedures such as fire evacuation, disaster preparedness, etc.
GENERAL POLICIES
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POLICY: Home Health Agencies
Residents may receive services from a Home Health Agency. Services will be
coordinated by the community Executive Director or Director of Wellness.
Procedure
1. Verify appropriate physician orders for the use of a Home Health Agency.
2. The Executive Director provides clarification of the scope of practice in an
Vantage Pointe Village community (e.g. prohibited conditions, etc.), as
well as community policies regarding privacy, sign-in/sign-out, reporting
suspected abuse, etc.
3. The community Executive Director, resident, and other appropriate parties
will be involved in the development of the Home Health Agency plan of
care.
4. Home Health Agency staff are expected to check-in with the Executive
Director when arriving at the community and when leaving.
5. The Home Health nurse should notify the Executive Director of any
significant change in a resident's condition/services to provide continuity of
care and to allow for monitoring of prohibited or restricted conditions.
6. The Executive Director shall make the Home Health Agency aware of all
new orders, medication changes and response to interventions performed
by community staff.
7. The home health agency is expected to give notice to the resident of the
time of the visit.
8. A home health agency shall not provide training nor expect a non-licensed
care giver to perform any prohibited act/service in the community.
Examples of prohibited acts include, but are not limited to:
a. Non-licensed staff filling insulin syringes.
b. Dressing changes.
c. Wound irrigation.
GENERAL POLICIES
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POLICY: Motorized Mobility Devices
Residents using motorized mobility devices, also known as scooters, are asked
to ensure the safety of all by observing the following rules.
Procedure
1. Written physician approval/authorization shall be received for each
resident using a motorized mobility device.
2. Carts are to be parked in the resident room or patio when not in use.
3. Carts are to be driven on the right side of hallways whenever possible.
4. Extreme caution is to be used when pulling out around blind turns,
corners, etc..
5. Carts are to be kept a safe distance behind all pedestrians, following the
manufacturer's guidelines for safe stopping distances.
6. Utmost courtesy is used to prevent rushing other residents on foot, in
wheelchairs or using other types of mobility aids.
7. Never drive carts when under the influence of alcohol or medications that
could pose a safety hazard, anywhere on the premises.
8. Personal Assistants will assist residents into any areas not safely
accessible by carts
9. In community rooms, carts should enter first and be the last to exit, unless
otherwise instructed for resident safety.
10. Always keep carts in good repair to ensure safety.
11. Appropriate insurance is to be carried by all cart drivers/owners with
minimum coverage in the amount designated by community.
12. Carts are to be driven on the lowest possible speed at all times when
indoors.
GENERAL POLICIES
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POLICY: Resident Transportation
Resident transportation needs will be met.
Procedure
1. Before Transporting
a. Post notices of scheduled transportation in a clear, easy to read
format. Explain schedules to visually or other disabled residents.
b. Ensure special arrangements are made for residents with special
needs.
c. Resident’s families are asked to place transportation requests a
minimum of 36 hours prior to the appointed time.
2. For Resident Safety
a. Residents are to have the cognitive and physical ability to be
transported without assistance. This is to be verified by a physician
statement. Otherwise, residents are not allowed to be transported
without assistance.
b. Should a resident require accompaniment/assistance of any kind,
the Executive Director arranges such assistance prior to
transportation of the resident.
c. Community vehicle drivers are to be notified verbally and in writing
of all residents who are not safe to leave the building without an
escort.
3. All community drivers are to be appropriately licensed, in good health,
drug free and safe to operate a motor vehicle.
4. A safety check of the vehicle is to be performed by the driver before
operating the vehicle.
GENERAL POLICIES
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POLICY: Resident Independent Departure
Assessment
Residents will be appraised for the ability to depart the community independently.
Procedure
1. Each resident will have a physician verification of the ability to leave
unescorted.
2. Should a physician not concur that the resident is able to leave without an
escort the resident will be encouraged to have staff accompaniment on
outings.
a. This is documented in the resident's record, and the responsible
party if notified.
3. Eviction will be considered for residents who are not safe to leave without
supervision, yet insist on leaving independently.
GENERAL POLICIES
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POLICY: Sign-In/Sign-Out
Residents are asked to sign-in and out when arriving at and leaving the
community.
Dementia Note: Should the community serve residents with dementia a more
appropriate policy would be necessary.
Procedure
1. Residents are asked to sign out when leaving the community. The person
accompanying the resident is noted as well as the time.
2. Residents may not be required to disclose their destination. However, for
safety purposes the resident’s destination may be recorded if it is
voluntarily disclosed.
3. Residents leaving for extended periods should notify the front desk.
4. If residents are out during meal time, it is requested that staff be notified
that the resident will be out.
5. Upon returning to the community, resident or staff may sign them in.
GENERAL POLICIES
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POLICY: Firearms
To ensure the safety of residents and staff firearms and ammunition are not
permitted within any part of the community.
Procedure
1. Prior to admission, residents will be informed of the prohibition of any
firearm or ammunition within any part of the community.
2. On admission the resident and or responsible party, as appropriate will be
asked if any firearm is being brought into the building.
3. Should a staff member suspect or identify a firearm or ammunition is
present in the community, their immediate supervisor is to be notified
immediately.
a. The Executive Director will be notified by the supervisor and
appropriate steps will be taken to remove the firearm.
b. If the resident refuses to allow the firearm to be removed, or at any
time staff or resident safety is in danger, the police or sheriff will be
notified immediately by calling 9-1-1.
GENERAL POLICIES
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POLICY: Personal Rights
Staff will observe and respect the personal rights of all residents residing in the
community.
Procedure
Staff respects each resident’s personal rights, which include, but are not limited
to, the right:
1. To be accorded dignity in his/her personal relationships with staff,
residents, and other persons.
2. To be free from corporal or unusual punishment, humiliation, intimidation,
mental abuse, or other actions of a punitive nature, such as withholding of
monetary allowances or interfering with daily living functions such as
eating or sleeping patterns or elimination.
3. Leave or depart the community at any time and to not be locked into any
room, building, or on community premises by day or night.
4. To visit the community prior to residence along with his/her family and
responsible persons.
5. To have his/her family or responsible persons regularly informed by the
community of activities related to his care or services including ongoing
evaluations, as appropriate to the resident's needs.
6. To have communications to the community from his/her family and
responsible persons answered promptly and appropriately.
7. To be informed of the community's policy concerning family visits and
other communications with residents.
8. To have his/her visitors, including ombudspersons and advocacy
representatives permitted to visit privately during reasonable hours and
without prior notice, provided that the rights of other residents are not
infringed upon.
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9. To wear his/her own clothes; to keep and use his/her own personal
possessions, including his/her toilet articles; and to keep and be allowed to
spend his/her own money.
10. To have access to individual storage space for private use.
11. To have reasonable access to telephones, to both make and receive
confidential calls. The licensee may require reimbursement for long
distance calls.
12. To mail and receive unopened correspondence in a prompt manner.
13. To receive or reject medical care, or other services.
14. To receive assistance in exercising the right to vote.
15. To move from the community.
16. To have the freedom of attending religious services or activities of his/her
choice and to have visits from the spiritual advisor of his/her choice.
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POLICY: Dignity
Each resident has the personal right to be accorded dignity in his/her personal
relationships with staff, residents, and other persons.
Procedure
1. Staff are respectful and courteous in all interactions with residents.
2. Staff refer to residents by proper name (e.g. Mr. Smith or Mrs. Jones),
unless requested to use another name by the resident or responsible
party.
3. When addressing personal care needs (e.g. bathing), staff will speak with
residents in a private location.
4. Privacy is provided to avoid creating a sense of humiliation or
embarrassment for a resident.
GENERAL POLICIES
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POLICY: Corporal Punishment and Restraints
Each resident has the personal right to be free from corporal or unusual
punishment, humiliation, intimidation, mental abuse, or other actions of a punitive
nature, such as withholding of monetary allowances or interfering with daily living
functions such as eating or sleeping patterns or elimination.
Procedure
1. Corporal or unusual punishment, humiliation, intimidation, mental abuse,
or other actions of a punitive nature are never used in caring for a
resident.
2. Physical or chemical restraints of any kind are never used in this
community.
GENERAL POLICIES
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POLICY: Complaints
Each resident has the personal right to be informed by the Executive Director (or
a Director of Wellness) of provisions of law regarding complaints and of
procedures to confidentially register complaints, including, but not limited to, the
address and telephone number of the complaint receiving unit of the licensing
agency.
Procedure
1. At the time of admission the Executive Director (or a Director of Wellness)
informs the resident and his/her responsible party of the internal
community complaint policy and procedure.
2. At the time of admission the Executive Director (or a Director of Wellness)
informs the resident and his/her responsible party of the desire by the
community and all community to accommodate resident requests, needs,
complaints, and concerns.
3. At the time of admission the Executive Director (or a Director of Wellness)
provides the resident and his/her responsible party a method of contacting
the Ombudsman.
4. At the time of admission the Executive Director (or a Director of Wellness)
informs the resident and his/her responsible party of provision for
registering complaints with the state licensing agency. This includes, at a
minimum, the address and telephone number of the complaint-receiving
unit of the licensing agency.
5. Personal Assistants bring all resident requests, concerns, and/or
complaints to the attention of his/her immediate supervisor or the
Executive Director.
6. The Executive Director (or Director of Wellness) investigates all
complaints and discusses his/her findings with the resident and his/her
responsible party.
7. The Executive Director (or a Director of Wellness) reports all substantiated
serious or repeated complaints to the local state licensing agency (as
required by state regulation).
STAFFING
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Staffing
STAFFING
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Staffing Introduction
This section includes sample staff position titles, job descriptions, duty schedules
and forms used for communication with and between employees.
The manual uses the title Resident Care Coordinator for a supervisory position
for the Personal Assistants. Other titles commonly used for this position include:
• Vantage Pointe Village Director
• Director of Resident Services
• Director of Vantage Pointe Village
• Supervisor of Personal Care
• Shift Supervisors
This manual refers to the direct care providers in the Vantage Pointe Village
community as Personal Assistant. Again, there are other common names also
used within this industry such as:
Care Givers
Care Aids
Resident Aids
Personal Care Assistants
Resident Attendants
Certified Nurses Aids (only with proper certification)
Choose what fits your community best and make necessary changes to this
manual.
In this employee section there exists some “universal staffing,” in that you will
see Personal Assistants performing some housekeeping duties. The idea of
cross training may be greatly extended in your community or you may prefer a
more narrowly defined job role than what is described within these pages. There
exists tremendous flexibility within the Vantage Pointe Village and residential
care industry to staff in a manner which reflects the best standard of care based
on your resident population, size of community, and other factors. When working
within an Vantage Pointe Village community, the staffing patterns should reflect
the needs of your senior population.
This section is not intended as an exhaustive human resources reference, but
rather focuses on resident care issues and the providers of the direct care
services. In your community you will likely have addendum support staff in other
STAFFING
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departments for such services as housekeeping, food services, groundskeepers,
maintenance, financial operations, etc.
POLICY: Staff Training
Direct care staff will Residents will receive initial orientation and ongoing in-
service training based on state regulations and the needs of the residents being
served in the community.
Implementation
1. Training on the following topics is included during Personal Assistant
orientation training and ongoing in-services.
a. Professional and ethical conduct, confidentiality, and reporting
requirements.
b. Promoting resident dignity, independence, privacy, self-
determination, choice and resident rights.
c. Abuse, neglect, exploitation and reporting requirements.
d. Fire, safety and emergency procedures, including identification of
unsafe environmental factors.
e. Infection control and Standard Precautions.
f. Emergencies, evacuations, disasters, incident reporting,
g. Advanced directives and Do-Not-Resuscitate Orders.
h. Psychosocial care and social, recreational activities.
i. Diversity: cultural, age, gender, sexual orientation, spiritual beliefs,
socioeconomic status, language, ethnicity, racial issues, etc.
j. End of life care and ethical issues.
k. Special care needs, aging issues, age-related limitations.
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l. Providing physical care, assisting with ADLs, encouraging
independence, lifting and transferring techniques, use of care
equipment (e.g. lifts).
m. Nutritional issues.
n. Documentation and recordkeeping.
o. Service plans, assessments, appraisals, resident summaries,
person-centered care, and end of shift reports.
p. Dementia care, managing behavioral challenges, wandering and
elopement (as applicable).
q. First Aid and CPR (as applicable).
r. Medication management (as applicable).
2. All training will be documented. Copies of documentation will be retained
in the employee record.
STAFFING
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POLICY: Job Description: Executive Director
Department: Administrative
Reports to: Licensee
Description of Position:
The Executive Director is fully responsible for community operations and quality
of care. Financial stability of the community, staffing practices and day to day
operations are coordinated by the Executive Director to fall within the operational
guidelines of governmental agencies. The Executive Director structures the
environment which will produce the highest standards of non-medical care.
Responsibilities of the Executive Director:
1. Identify and develop community standards of care congruent with the
population seeking placement.
2. Project and develop a sound operating budget for the community.
3. Standardize operations of each department.
4. Maintain the community in compliance with regulatory agencies.
5. Develop sound policy and procedure for resident care.
a. Utilize a system of sound management which monitors quality standards on
an ongoing basis in all departments.
6. Develop and carry out a successful marketing program which maintains >
95% occupancy.
7. Approve all admissions.
8. Hire new staff and/or terminating of unsatisfactory staff.
9. Investigate theft/loss in the community.
10. Carry out the operating policy of the licensee.
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POLICY: Job Description: Assistant Executive
Director
Department: Administrative
Reports Directly to: Executive Director
Description of Position:
Provides direct supervision of department heads. Works with the community,
ensuring that the community is a positive choice for seniors in the area.
Coordinates all departments to promote outstanding community operations in
alignment with goals, budget guidelines and resident needs. Assumes
responsibilities of the Executive Director in his or her absence, following
community guidelines. Supervises operations to conform to regulatory
guidelines.
Responsibilities of the Assistant Executive Director:
1. Supervise all department heads to ensure community is operating
according to standards and in compliance with regulatory guidelines.
2. Implement department budget and approve or deny expenditures based
on the allocations set by the Executive Director.
3. Work within the community to place residents in need of a higher level of
care.
4. Market the community to prospective placements. Schedule and plan all
community outreach projects.
5. Coordinate move-ins with other department heads.
6. Assume full responsibility all regulatory guidelines forms and
documentation for residents and employees and ensure that
administrative operation is up to date and complete at all times. Secure all
admission paperwork prior to move-in.
7. Organize monthly resident and family council meetings as well as family
conferences.
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8. Prepare all licensing requests for exceptions, waivers and exemptions for
Executive Directors review and signature.
9. Monthly review of vendor performance.
10. Initial screening for all new job applicants. Verify qualifications.
11. Criminal clearances and coordination of pre-employment documentation.
12. Coordinate employee performance reviews.
13. Investigate complaints, document and review with Executive Director.
14. Terminate unsatisfactory staff with approval from Executive Director.
15. Other duties as assigned.
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POLICY: Job Description: Resident Care Coordinator
Department: Resident Care Services
Reports to: Executive Director
Description of Position:
The Resident Care Coordinator works as a liaison between residents, resident
families, and staff. The Personal Care Coordinator’s duties also include problem
solving resident concerns and coordinating care with the Personal Assistants.
The Personal Care Coordinator may be an RN or LVN when necessary.
Staffing Pattern:
The community has one Personal Care Coordinator position, on days only. This
is the chief supervisory position for the Personal Assistants who provide primary
care to their resident assignment.
Responsibilities of the Personal Care Coordinator:
1. Personal Assistant scheduling and resident assignments, working within
the department allowances.
2. Coordinate admissions with assistant Executive Director including
supervising move-ins to be sure accommodations are as desired and care
is immediately implemented.
3. Family/resident admission interviews.
4. Immediately bring prohibited conditions or at-risk residents in need of a
higher level of care to the attention of the assistant Executive Director.
5. Coordinate care planning with home health agencies on site, working
within community policy.
6. Arrange for transportation as desired by the resident.
7. Arrange for resident special needs involving other departments, verifying
follow through.
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8. Function as a liaison with families ensuring special
needs/requests/complaints are addressed. Inform assistant Executive
Director, in writing and verbally, of all family or resident complaints.
9. Monitor staff performance, providing or arranging assistance as needed.
10. Read all communication notes regarding the community between the
Personal Assistant shifts.
11. Coordinate staff training and in-service schedules with the Assistant
Executive Director
12. Supervise the medication room and orders, working with and supervising
Medication Aides and Personal Assistants.
13. Other duties as assigned.
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POLICY: Job Description: Medication Aide
Department: Resident Care Services
Reports to: Personal Care Coordinator
Description of Position:
Coordinates resident care related to medications by working with all
departments, the medical community, families and administrative staff to provide
for resident needs with continuity and an adherence to the scope of practice and
licensure for the community. Provides complete supervision of the medication
room, pass techniques, documentation and supervision and provision of care
related to medication in the community.
Staffing Pattern:
The community has one Medication Aide on each shift.
Responsibilities of the Medication Aide:
1. Resident charts. Keeping documentation current (Community forms,
licensing documentation, physician orders, incident reports., etc.)
2. Communicate resident status changes.
3. Ensure all medication documentation is current and correct, including
medication administration forms, physician orders, change of dosages,
written orders to confirm telephone orders, etc.
4. Ensure medication room is completely stocked with all required
continuous, PRN, Over-the-Counter (OTC), and other medications as
ordered by the physician.
5. Coordinate medication orders and deliveries with pharmacies
6. Communicate with physicians and other healthcare providers as needed.
7. Monitor Psychotropic med use is congruent with physician orders and
ensuring resident behaviors actually warrant the use of medication.
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8. Control medication room access and key assignment.
9. Pour, pass, and assist with administration of medications in accordance
with state regulations.
10. Coordinate physician and other medical appointments.
11. Read all communication notes regarding the community between the
Personal Assistant shifts.
12. Other duties as assigned.
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POLICY: Job Description: Personal Assistant
Department: Resident Care Services
Reports Directly to: Personal Care Coordinator
Description of Position:
Provides direct personal care and supervision to the residents at the community.
Promotes resident well being and satisfaction through support with activities of
daily living. Communicates with other departments to ensure resident needs are
met.
Staffing Pattern:
The Resident Care Services department at this Vantage Pointe Village
community staffs through a primary care structure. Each Personal Assistant will
be charged with all of the personal care duties of their resident assignment.
Whenever possible each Personal Assistant will be assigned to the same
resident group each day to promote continuity of care.
Responsibilities of the Personal Assistant:
1. Assist with activities of daily living, including passing medication as
assigned, following community protocol, licensing regulation and
guidelines for both resident and employee safety.
2. Follow safety guidelines in the community, including proper lifting
technique and universal precautions when providing care to the residents.
3. Follow the schedule of duties for the Personal Assistant, as well as the
individual plan of care for each resident.
4. Function as a team, assisting coworkers as the need arises.
5. Monitor resident activity, food intake, functional status, psychosocial
status, taking action as required to promote resident wellbeing.
6. Report status change immediately to the supervisor.
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7. Act immediately on any resident crisis, following protocol and basic first
aid training.
8. Document resident status change, including but not limited to, physical
change, reaction to medication, psychosocial status change.
9. In the event all assigned duties cannot be completed, ask for assistance
and report to the personal care coordinator.
10. Any other assignments made by your direct supervisor or Executive
Director.
11. Promote open communication between health care professionals, families,
residents and staff.
12. Adhere to guidelines in the employee handbook including dress code,
conduct, scheduling, etc.
13. Other duties as assigned.
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POLICY: Volunteers
Students and/or volunteers will be utilized as appropriate. Procedures will
ensure the safe, competent and mutually beneficial performance of volunteers.
Implementation
1. Signed Agreement
a. All volunteers will sign a written volunteer agreement.
2. Job Functions
a. Volunteers work under the direct supervision of the Director of
Activities.
b. Job functions will be specified by the Director of Activities for each
volunteer.
c. Job functions may include: assisting with activity programs,
assisting during activity outings, organizing activity supplies,
arranging for outings and special events.
d. All job functions will adhere to state-specific regulations.
3. Scope of Responsibility
a. Volunteers will not be assigned responsibility to supervise
community staff, Personal Assistants, nurses, etc.
b. Volunteers are responsible for ensuring the safety, well-being and
personal rights of residents involved in their activities.
4. Criteria for Use/Supervision
a. Use of volunteers will adhere to state-specific regulations.
b. Volunteers are under the direct supervision of the Director of
Activities.
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5. Orientation and Training
a. Volunteers will receive necessary orientation and training from the
Director of Activities.
b. Orientation and training will address:
i. Introduction to program and philosophy.
ii. Volunteer responsibility.
iii. Attendance.
iv. Reporting.
v. Safety.
vi. Delayed egress and/or alarm systems (if applicable).
vii. Confidentiality.
viii. Abuse reporting.
ix. Overview of resident-specific care or health issues.
6. Dismissal
a. Volunteering is at the mutual consent of the community and the
volunteer. Either party may terminate the relationship at any time,
with or without cause and with or without advance notice.
7. Confidentiality
a. Volunteers will respect and ensure the confidentiality of all resident,
staff and community information.
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Admissions and
Move-In
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POLICY: Resident Pre-Admission Appraisal
The Executive Director will gather data on each potential resident to determine
the need and type of services to be provided.
Procedure
1. The Executive Director meets with the resident and responsible party prior
to admission.
2. The Resident Appraisal is completed by the Executive Director.
3. The Executive Director begins the pre-placement meeting with proper
introductions and explanations to promote a milieu of trust, comfort, and
honesty. Open-ended questions are encouraged. Consent is obtained for
the appraisal.
4. The purpose of the appraisal is explained: to determine the level and type
of services/care needed by the resident and that will be available for the
resident at the time of move-in, as well as to meet state licensing
requirements. The resident and/or family is assured by the Executive
Director that honesty and detail regarding care needs is in the best interest
of the resident.
5. Communicate acceptance by use of proper body posture, nods of
understanding and allowing the resident ample opportunity to answer
questions.
6. The Executive Director reviews the Physician Report for any prohibited
conditions or communicable illness.
7. Absence of TB must be evidenced by a physician report or chest x-ray
within the last six months.
8. The resident and/or responsible party are questioned about skin
breakdown.
9. A medication review will include the following:
a. Review of all medications on hand or reported.
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i. NOTE: A physician order is to be obtained prior to
admission day, verifying medications and dosing schedule.
b. Specifically ask about the use of OTC (Over-The-Counter)
medications and complimentary or alternative medicines. Note any
preferred OTC medications to ensure physician orders are secured
prior to admission.
i. NOTE: This is an opportunity for resident teaching regarding
the storage and use of OTCs, related to regulatory
guidelines.
c. Should a resident desire to retain his/her OTC medications, a
physician order is obtained indicating the resident may self-store
and self-administer medications.
d. When OTC medications are centrally stored, a physician order is
required for all routine medications prior to assisting with the
medication.
e. When the OTC is a PRN and centrally stored, the following must be
included in the physician order:
i. Name of drug
ii. Strength of drug
iii. Dosage
iv. Exact time frames between doses
v. Maximum dose in a 24 hour period
vi. Symptoms for which the medication is used
10. Information regarding alcohol consumption is obtained.
11. Prohibited health conditions and/or residents significantly at risk are
identified. See the policy on prohibited health conditions for more
information.
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POLICY: Allowable Health Conditions
The community will admit and retain stable residents with health conditions that
can be safely cared for by community staff and are in compliance with state
licensing agency guidelines.
Procedure
1. A physician's report is reviewed prior to placement to verify diagnoses and
health conditions.
2. The Physician Visit form is used to monitor health status changes after the
resident is admitted.
3. The following are examples of health conditions/needs that may be
managed in the community.
a. Use of oxygen when blood gases are stable and the resident is
capable of self-administration.
b. Colostomy, when the resident is able to manage all aspects of the
condition.
c. Ileostomy, when the resident is able to manage all aspects of the
condition.
d. Incontinence (both bowel and bladder).
e. Stage I and II decubitus ulcers.
f. Post-surgical wounds when the wound is well approximated.
g. Diabetes, including insulin-dependent, providing the resident has
reasonable stability, and is able to self-test and self-inject.
h. Inhalation therapies.
i. Hospice, providing a Medicare certified hospice agency, contracted
by the resident/responsible party, is coordinating the care.
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4. Mild to advanced dementia, providing the community is appropriately
licensed.
5. Before accepting or retaining a resident with any of the above allowable
health condition, an assessment/evaluation of the resident must be
completed to confirm:
a. Resident's ability for self-care.
b. Compliance with the care routine to maintain medical stability and
consent to additional services whether by the community staff or
outside contracting agencies.
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POLICY: Day of Admission/Move-In
The resident’s needs are addressed during the move-in process.
Procedure
1. The Executive Director coordinates the following on move-in day to ensure
appropriate resident care.
a. All preadmission documentation is complete and in the resident’s
chart.
i. The chart is appropriately labeled and organized.
b. The service plan is completed.
c. All physician admission orders are received.
d. Medications
i. All new prescriptions are sent to the pharmacy for same day
delivery, or if using existing fills, medications are verified.
ii. The medication cart/storage area is labeled and organized.
iii. The MAR (Medication Assistance Record) is set up,
including resident photograph in place.
e. Personal Assistants are assigned to assist the resident to put
belongings away and settle into his/her room.
i. The assigned Personal Assistant checks with the newly
placed resident every 4-6 hours for the first 24 hours of
placement, unless otherwise requested by the resident.
5. The Executive Director meets with the resident at the time of move-in for a
brief safety survey of the room and to verify that the resident is stable.
6. The Executive Director orients Personal Assistants about the needs of the
newly admitted resident on each shift.
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POLICY: Change in Condition
When a resident exhibits a change in condition, action will be taken to coordinate
appropriate care.
Procedure
1. When a resident displays a change in condition, Personal Assistants notify
the Executive Director.
2. If a change in status progresses to an emergency at any time, call 911.
3. Examples of change in condition may include, but not be limited to:
a. Refusal of meals
b. Decreased mobility/range of motion
c. Change in patterns of elimination
d. Weakness
e. Decreased coordination
f. Change in level of consciousness
g. Decreased communication/response
h. Decreased ability to communicate signs
i. Decline in cognitive function
j. Motor agitation or retardation
k. Hallucinations or other unusual behavior
l. Nausea
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m. Vomiting
n. Elevated or subnormal temperature
o. Wheezing
p. Shortness of breath or exertion
q. Complaints of pain or discomfort
r. Edema or swelling
s. Change in usual range of vital signs
t. Reaction/side effect to medications
u. Weight loss
v. Depressive behaviors
w. Falls
4. If there is an actual change in condition the resident’s physician is notified.
Always have the resident’s complete chart, list of meds, current vital signs
(if available), and concise list of problems available when calling the
physician.
5. If this is part of an ongoing problem and home health or hospice are
following the resident, contact the home health or hospice nurse and
explain the situation at hand.
6. Document the date and time of contacts, and with whom you spoke.
Clearly document any new orders and repeat back to the physician.
7. Immediately enter the new orders on the resident’s service plan and/or
medication administration record if the order pertained to medications.
8. Notify the resident’s responsible person of the change in status and action
taken.
9. Keep the Executive Director abreast of the resident’s response to the new
orders.
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10. Report the status change and new physician orders to each shift.
11. If the resident status change results in a prohibited health condition, a
conference will take place with the Executive Director to determine the
resident’s suitability for retention. The Executive Director will file for an
exception if required.
12. If the resident requires skilled monitoring due to the status change, the
Executive Director consults with the physician to obtain an order for home
health.
13. The Wellness Director documents, schedules and follows through with any
continuing physician appointments and medical care.
14. If the resident status change is more than a transient problem, a resident
care conference is arranged.
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POLICY: Ongoing Resident Appraisals
Residents are assessed/evaluated on an ongoing basis.
Procedure
1. Daily Evaluations
a. All staff members are encouraged to informally monitor residents
on a regular basis throughout the course of normal daily activities,
and to report any changes in condition that are identified.
2. One-Month Resident Appraisal
a. Resident will be formally assessed thirty days after admission.
b. The Executive Director meets with the resident and/or responsible
party to verify the resident’s needs are met.
c. The Executive Director consults with other Personal Assistants and
staff to ensure the resident’s needs are met.
d. The service plan is updated as necessary.
3. Quarterly Resident Appraisal
a. Residents are formally assessed on a quarterly basis.
b. The service plan is updated as needed.
c. Rates are adjusted, congruent with care delivered, and in
accordance with the terms of the admission agreement.
d. The Wellness Director consults with other Personal Assistants and
staff to ensure the resident’s needs are met.
4. Stakeholders
a. The following key stakeholders are encouraged to participant in
resident appraisals and service plan updates:
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i. The resident
ii. The Executive Director
iii. The resident's responsible party
iv. Selected members of the community's care staff
v. Appropriate healthcare professionals (e.g., home health
nurse, physical therapy, etc.)
vi. The resident's physician
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POLICY: Activity Assessments
The activity preferences of each resident will be determined to aid in the
development of a resident-centered activity plan.
Procedure
1. The Executive Director or a designated representative interviews the
resident and his/her responsible party regarding the resident’s personal
activity history and preferences.
2. The following domains should be addressed during the interview:
a. Gross motor activities
b. Daily living skills
c. Self-care activities
d. Crafts
e. Interest in social programs, games, music
f. Interest in large and small group participation
g. Social events
h. Community activities
i. Sensory enhancement, tactile stimulation
j. Outdoor activities, field trips
k. Family events
3. Use the Resident Activity Assessment form to document the assessment.
4. Information from the assessment is used to develop a resident-centered
activity plan and schedule.
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POLICY: Admission Agreements
Each resident (or responsible party) signs an admission agreement prior to
admission.
Procedure
1. The resident and his/her responsible party is provided a copy of the
admission agreement prior to admission.
2. Prior to admission, the Executive Director meets with the resident and
responsible party to discuss the agreement as well as all fees and the plan
of care.
3. The admission agreement must be signed prior to admission.
4. Resident is given a thirty day notice of any subsequent changes to the
agreement.
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POLICY: Service Plans
A resident-centered service plan is created and maintained for every resident.
The purpose of the service plan is to provide a centralized coordination of the
services that will be provided to each resident, based on his or her individual
needs, abilities, and preferences.
Procedure
1. The Executive Director, or a designated representative, develops a service
plan for each resident prior to admission.
2. The service plan is developed with assistance and review from:
a. The resident.
b. Family/significant other or responsible party.
c. The Executive Director (or designee).
d. A registered or licensed nurse, if the resident is receiving nursing
services, medication assistance, or is unable to direct self-care.
e. The resident’s case manager (if applicable).
f. The team may also include (at resident’s or responsible party’s
request): community personnel, his/her physician, and other
persons as requested.
3. The service plan should address, but is not limited to, the following:
a. Activities of Daily Living (ADLs).
b. Medication management and/or assistance required.
c. Physical needs related to illness/chronic disease management.
d. Psychosocial needs including activities
e. Behavioral challenges/needs
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f. Spiritual needs.
g. Fall history and/or risk.
h. Nutritional needs such as help with eating or special diet.
i. Skin integrity issues.
j. Any need identified by the family or resident.
k. Activities.
l. Transportation needs.
4. A copy of the service plan is available to all staff for review.
5. A current copy of the service plan, signed by the resident and/or
responsible party is retained in the resident’s record.
6. All direct care staff are encouraged to give input on service plan changes.
7. Formal review takes place:
a. Thirty days after admission.
b. Bi-annually.
c. Annually.
d. Upon significant change in resident status/condition.
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POLICY: Resident Care Conference
The resident care conference is intended to encourage a multidisciplinary
approach to resident care planning that involves input from all relevant
stakeholders.
Procedure
1. Purpose of Resident Care Conferences:
a. To identify individual resident needs.
b. To collaborate with all stakeholders in the coordination of optimal
resident care, ensuring clear communication of the plan of care.
c. To evaluate effectiveness of previous interventions and current
resident status.
d. To develop resident-centered interventions and methods of care for
the individual resident.
e. To coordinate discharges/evictions for those residents at risk for
transfer trauma.
2. Indications for Resident Care Conference:
a. Upon admission of a new resident.
b. Upon readmission of a resident if there has been a change in status
or previous functional abilities.
c. Resident is at risk of move-out or discharge.
d. Change in resident status or condition.
e. Annual resident appraisal and service plan review.
3. Attendees at the resident care conference may include, but are not limited
to:
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a. Executive Director
b. Wellness Director
c. Appropriate department heads.
d. The resident
e. The resident's responsible party
f. Home health nurse
g. Other health care providers as appropriate (e.g., hospice, physical
therapy, etc.)
4. Documentation/Information
a. Conferences are to be resident focused at all times. It is the
responsibility of the Wellness Director to have all of the following
information available at the conference:
i. Resident’s history.
ii. A copy of the entire resident charting for the last 60 days.
iii. List of current medications.
iv. Significant health history.
v. Incident reports.
vi. Current service plan.
vii. All other relevant history and information.
viii. Current MD orders.
5. Suggest Conference Agenda
a. The conference general agenda is as follows:
i. Identify the resident.
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ii. State purpose of conference (at risk, status change, etc.)
iii. Brief history.
iv. Current medications & Physician orders.
v. State chief problems/concerns.
vi. Discussion/identification of needs.
vii. Review/critique of previous interventions and plan of care.
viii. Discussion, revision and formulation of current plan of
action.
ix. Interventions.
x. Identification of individuals to carry out each intervention.
xi. Schedule of follow up conference date (as necessary) to
evaluate status and interventions.
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POLICY: Move-Out
Residents may move out of the community for a variety of reasons, such as
increased need for healthcare services, a change in condition, or family/personal
reasons. A move-out of the community (discharge) is conducted in a dignified
manner to limit transfer trauma and to ensure that resident needs are met.
Procedure
1. The Executive Director coordinates the timing of the move-out with the
responsible party and receiving community or new residence.
2. If ambulance transportation is necessary, it is arranged by the Wellness
Director or the nurse on duty.
3. The Wellness Director assigns a staff member to assist resident with
collecting and packing belongings, as needed.
4. The resident is dressed in appropriate street clothing if going by car.
Gown, pajamas, etc., may be worn if going by ambulance.
5. The Personal Assistant assigned to the resident ensures hearing aid,
dentures, etc., are in place and appropriately accounted for.
6. The resident’s medications are counted and packaged appropriately for
transportation. The person receiving the medications upon transfer signs
for their receipt, accepting and acknowledging responsibility for
safekeeping.
7. All treatments and medication given within the last 24 hours are indicated,
and passed on to the new community.
8. A resident move-out summary is completed in the resident's record.
9. The resident's record is archived.
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Resident Care
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POLICY: Basic Care Services
Personal care will be provided to all residents on an individual basis according to
findings from admission appraisals and subsequent re-appraisals.
All resident care is planned and delivered in a resident-centered manner, and
personal service plans should address any individual resident needs.
Procedure
1. At the beginning of each shift, staff should familiarize themselves with
resident status. Clear communication with staff from the previous shift,
using the shift report and verbal exchange, ensures quality care.
2. Each resident is monitored on a routine basis. Check on residents every
two hours, unless indicated otherwise on the resident’s service plan.
a. NOTE: Residents with confusion or a diagnosis of dementia should
be checked on an on-going basis.
3. Incontinent care is given as necessary to residents requiring assistance
every two hours. This includes nighttime hours, unless the physician
orders indicate otherwise.
4. Medications are to be given according to physician orders and when
possible according to the following general medication pass schedule.
a. Morning medication pass: 7:00 A.M.
b. Mid-day medication pass: 11:00 A.M.
c. Evening medication pass: 5:00 P.M.
d. Bedtime medication pass: 8:00 P.M.
e. A "two-hour window" ensures appropriate delivery of medications.
Medications may be passed one hour earlier or one hour later
unless indicated otherwise by the physician or authorized
prescriber.
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5. PRN medications are administered according to physician orders, resident
requests, and state regulations.
6. Residents are assisted with morning care as needed, which may include
but is not limited to the following :
a. Clothing selection.
b. Dressing.
c. Oral care.
d. Assistive devices, such as eye glasses, hearing aids, etc.
e. Shaving.
f. Cosmetics.
g. Hair care.
7. Residents are to have a full shower/bath according to their needs and
preferences, and at least twice per week.
8. Residents needing a reminder or assistance with ambulation or escorts
are to receive assistance to the dining room as needed for all three meals
and snacks as necessary.
9. Each resident is to have his or her room tidied and bed made each day if
unable to do so independently. Complete cleaning of their quarters is
performed by housekeeping staff on a weekly basis.
10. Residents are encouraged to select and attend activities. It is the
responsibility of the Personal Assistant to remind the resident of upcoming
activities throughout the day.
11. Residents receive assistance with bedtime/evening care as needed, which
includes, but is not limited to the following:
a. Oral care.
b. Dentures in a labeled cup.
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c. Assistance into night clothes.
d. Toileting.
e. Incontinence care.
f. Safety check of the room.
g. Remove physical obstacles to the bathroom, and leave a low light
on in the bathroom.
h. Room set to a temperature desired by/comfortable for the resident.
i. Monitor noise level.
12. Any unusual incident will be reported and documented. All pertinent
information on the resident will also be documented and passed on to the
following shift.
13. Resident status changes will be reported to the physician and resident's
responsible party, in accordance with the policy on Change in Condition.
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POLICY: Use of Assistive Devices and Ambulatory
Aids
The community promotes resident safety by allowing and encouraging the use of
resident assistive devices and mobility aids.
Implementation
1. The physician report and any pre-admission documentation will be
reviewed prior to placement, identifying resident need for assistive devices
or mobility aids.
2. The resident and responsible party are interviewed regarding resident
need for assistive devices or mobility aids.
3. Upon admission, the resident’s assistive devices and mobility aids are
labeled with name and room number.
4. Upon admission, residents are instructed about use of devices/aids within
the community:
a. Use in dining room.
b. Storage of devices for safety.
5. When a resident receives a new order for a mobility aid, the physician is
contacted to request a physical therapy consult for resident teaching.
6. In the dining room or common areas where an activity may cause some
congestion, resident’s mobility aids are moved to a designated area, once
the resident is seated safely. Staff will return the device to the resident
upon request, when the resident is ready to ambulate.
7. Any resident using a motorized scooter must demonstrate safe operation
of the device to the Executive Director. The Resident Care Coordinator also
obtains a written order verifying the ability for safe operation from the resident’s
physician. The resident must be re-evaluated for safety should any impaired
operation take place.
8. Safe use of mobility aids and assistive devices is included in staff
orientation.
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POLICY: Hygiene and Grooming
The resident’s hygiene and grooming needs are met while addressing the
resident’s personal preferences and daily routine.
Implementation
1. The Resident and responsible party are interviewed prior to move-in to
determine the resident’s preferences for the provision of hygiene and
grooming care.
2. The resident’s physician report and appraisal are reviewed to identify
resident needs and preferences.
3. Special care needs are addressed in the resident’s service plan.
4. Residents are showered daily if desired, and at a minimum twice a week.
Exceptions are allowed for residents with special conditions or needs,
such as skin disorders or certain disease processes.
5. Bed baths are given upon evidence of need. The Resident Care
Coordinator approves bed baths to be given on a regular basis.
6. Refusal of necessary hygiene and grooming is reported by Personal
Assistants to the Wellness Director and/or Executive Director. Continued
refusal of hygiene and grooming is noted in the narrative charting section
of the resident’s chart, and the Executive Director is notified for further
action.
7. Resident autonomy is encouraged. Residents are not encouraged to
accept services when there is evidence they are capable of providing
selfcare adequately.
8. Assistance is scheduled as indicated in the service plan.
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POLICY: Dressing
The resident’s need for assistance with dressing is met in accordance with the
resident’s personal preferences.
Implementation
1. The resident’s physician report will be reviewed to determine if assistance
is required.
2. Resident and family/responsible party are interviewed prior to move-in to
determine the resident’s preferences for the provision of hygiene and
grooming care.
3. Residents requiring assistance with dressing are encouraged to perform
as much of the task as possible.
4. The resident is expected to select or participate in the selection of his/her
clothing.
5. Residents are dressed in “street clothes” when in common areas of the
community.
6. Residents are assisted with additional clothing changes throughout the
day as needed.
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POLICY: Sleep and Rest
Sleep disturbances will be addressed to promote appropriate rest.
Procedure
1. Residents with insufficient or poor quality sleep are monitored and/or
interviewed for possible causative factors. The Executive Director and
Personal Assistants monitor for:
a. Bedtime and waking times
b. Bedtime rituals
c. Type of bedclothes
d. Frequency and duration of awake time
e. Activities usually performed in the early evening hours
f. Leisure activities
g. Medications taken
h. Perceived health status and satisfaction with life
i. Food or fluids consumed shortly before bedtime
j. Number of nightly trips to the bathroom
k. Frequency of need for pain medications or for help with toileting
l. Time spent out of bed
2. The Wellness Director initiates changes in care to improve sleep, such as:
a. Maintain the same daily schedule for waking, resting, and sleeping.
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b. Get up at the usual time even if the sleep has been disturbed or the
bedtime change temporarily.
c. Establish a bedtime ritual and stick to it.
d. Exercise every day but avoid vigorous exercises at night.
e. Limit naps to one or two hours per day, at the same time each day.
f. Take a warm bath in late afternoon or early evening.
g. Avoid caffeine-containing beverages and products.
h. Practice relaxation methods such as deep breathing, music,
rocking, massage, or reading calm materials.
i. Eat a light snack of carbohydrates and fat before bed.
j. If the resident is awake for longer than 30 minutes, get the resident
out of bed and engage in a non-stimulating activity such as reading.
3. When other methods have failed, the Wellness Director consults with the
physician for possible use of temporary sleep aids or other medical
interventions or assessments.
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POLICY: Incontinence
Residents suffering with incontinence will receive care and management aimed
towards restoring continence whenever possible and preventing incontinence
related complications.
Procedure
1. Should a resident have an episode of incontinence, the Executive Director
consults with the physician to investigate the following:
a. Problems with manual dexterity or mobility.
b. Problems or changes in the environment (access, distance to
toilets, etc.)
c. Problems with excessive fatigue.
d. Difficulty or painful voiding.
e. Problems with constipation/stool impaction.
f. Changes in diet, including increase in caffeine.
g. Changes in medications, such as addition of a diuretic.
h. Changes in behavior/affect.
i. Mental status.
2. The Wellness Director instructs Personal Assistants to track episodes of
incontinence. If the resident is alert, encourage the resident to track
episodes themselves.
3. The Wellness Director transmits the information on episodes of
incontinence and other pertinent information to the resident’s physician.
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4. The Wellness Director establishes a toileting schedule for staff to follow
when appropriate.
5. The Wellness Director consults with the physician to develop interventions
to correct incontinence whenever possible.
6. Should interventions fail and the resident is diagnosed with chronic
intractable incontinence, the service plan will include a skin management
plan.
7. Unless contraindicated, residents receive incontinent care and brief
changes every two hours, or more often as needed, to keep the resident
clean and dry.
8. Personal Assistants are instructed to monitor for and report any signs of
skin breakdown.
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POLICY: Nutrition and Weights
The community monitors weights and provides modified diets as ordered by the
physician.
Procedure
1. The Wellness Director assigns the task of measuring resident weights to
Personal Assistants (after appropriate training) on a monthly basis.
2. Weights are measured more often if ordered by the physician.
3. Weight measurements are recorded in the residents record on the weight
record form.
4. Weights are measured using the following guidelines:
a. Prior to breakfast, after first voiding, and with the same amount of
clothing each day.
5. A weight change of five pounds or 5% of body weight in a 30-day period,
whichever is greater, is reported to the physician.
6. Nutritional supplements will be offered to the resident as ordered by the
physician.
7. Modified diets will be provided as ordered by the physician.
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POLICY: Podiatry and Nail Care
The community will arrange for or make available foot and nail care.
Procedure
1. Personal Assistants monitor the length and condition of the toe and finger
nails of residents receiving bathing, dressing, or grooming services.
2. Personal Assistants note changes in residents’ nail or foot integrity.
3. Personal Assistants do not trim nails, smooth corns, calluses, etc.
4. The Wellness Director schedules a podiatry appointment for foot and/or
nail care, other than cleaning or moisturizing.
5. The Wellness Director arranges for regular (monthly preferred) onsite
visits by a podiatrist, as needed and as available.
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POLICY: Personal Assistant Daily Schedule
Personal Assistants are given assigned duties to ensure quality care.
This is only a basic policy and schedule. Always refer to the resident’s individual
plan of care for additional intervention.
11:00 pm - 7:30 am
1. Verify resident status changes with the previous shifts. Read
documentation.
2. Rounds every two hours.
3. Incontinent care every two hours as assigned, and as needed.
4. Housekeeping duties as assigned.
5. PRN medications as needed (med aides only).
6. Awaken first serving breakfast residents.
7. Assist with designated early morning baths.
8. Assist as needed with grooming: Resident morning grooming (assist only
as required)
a. Bathing (on designated days)
b. Incontinent care
c. Clothing selection
d. Dressing
e. Oral care
f. Assistive devices in place
g. Shave
h. Make-up
i. Hair care
j. Mini appraisal
9. First serving residents to dining room.
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10. Set-up and pass 7:30 am medications (medication aides only).
11. Assist second serving residents with personal care.
12. Document resident status change or incidents per community protocol.
13. Report off to next shift.
7:00 am - 3:30 pm STAFF DUTIES
1. Verify resident status changes with the previous shifts. Read
documentation.
2. Check schedule for resident physician or other scheduled appointments.
3. Designated resident baths.
4. Assist with resident grooming which was not completed by the night shift.
a. Bathing ( on designated days )
b. Incontinent care
c. Clothing selection
d. Dressing
e. Oral care
f. Assistive devices in place
g. Shave
h. Make-up
i. Hair care
j. Mini appraisal
5. Second service residents to dining room by 7:30 am.
6. Rounds every 2 hours.
7. Incontinent care every 2 hours as assigned.
8. Make beds.
9. Tidy rooms/housekeeping duties as assigned.
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10. Pass am snacks.
11. Residents to 10:00 am activities.
12. PRN medications as needed (med aides only).
13. Prepare and assist first serving residents to dining room for lunch.
14. Prepare and pass 11:30 am medications (med aides only).
15. Prepare and assist second serving residents to dining room for lunch.
16. Residents to early afternoon activities.
17. Afternoon grooming/room check.
a. Clean clothing
b. Wash face and hands
c. Tidy room
18. Pass afternoon snacks.
19. Document status change/incidents per protocol.
20. Report off to next shift.
21. Med staff only.
3:00 pm - 11:30 pm
1. Verify resident status changes with previous shifts. Check documentation.
2. Rounds every 2 hours.
3. Incontinent care every 2 hours.
4. Housekeeping duties as assigned.
5. PRN medications as needed (med aides only).
6. Set-up and pass 4:30 pm medications (med aides only).
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7. First serving residents to dining room at 4:30 pm. Second serving
residents to dining room at 5:30 pm.
8. Residents to pm activities.
9. Set-up and pass 8:30 pm medications (med aides only).
10. Assist residents as needed with evening care.
a. Oral care
b. Dentures in labeled cup
c. Assist into night clothes
d. Toileting
e. Incontinent care
f. Remove soiled clothing and put in hamper
g. Remove assistive devices (hearing aids, etc.)
h. Safety check
i. Pathway clear to bathroom
j. Room a comfortable temperature
k. Extra blankets, etc.
11. Check lighting.
12. Outside doors secured. (from outside only)
13. Document status change/incidents per protocol.
14. Report off to next shift.
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POLICY: Sexual Expression
The community respects the resident’s need for sexual expression and intimacy.
Procedure
1. Resident privacy is observed by scheduling for private time, knocking on
doors before entering, etc.
2. Verify the resident’s ability to give consent by consulting with the resident’s
physician for residents interested in pursuing sexual relationships.
3. When a resident displays inappropriate sexual activity / exposure, have
staff remind the resident of the need for privacy and then move the
resident to his or her room.
4. Discuss the resident’s sexual behavior with Personal Assistants.
Reinforce the idea that sexual behavior is normal and that acknowledging
a resident’s sexuality is appropriate.
5. Educate families about resident rights related to sexuality and the
normalcy of sexual expression.
6. When a resident interacts or touches staff inappropriately, the Executive
Director reinforces care techniques to avoid such problems. For example:
a. Identify yourself when ready to provide care.
b. Stand at the side, rather than in front of the residents reach when
providing personal care.
c. Give the resident something to hold when providing personal care.
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Medication
Management
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POLICY: Medication Storage
Medications will be stored in a manner that ensures maintenance of both the
integrity of the medication and the safety of all residents residing in the
community.
Procedure
1. All medications, including over-the-counter, are kept in locked storage at
all times.
2. All medications must be stored in accordance with label instructions
(refrigerate, room temperature, out of direct sunlight, etc.).
3. Medication requiring refrigeration are stored in a separate, locked
refrigerator that is used solely for medication storage.
4. If resident is allowed to keep his/her own medications, the Executive
Director ensures:
a. Locked storage is maintained in the resident’s room to prevent
access by other residents.
b. Physician orders are on file in the resident’s chart indicating the
resident is able to store and self-administer his/her medications.
c. Quarterly evaluation of the resident’s ability to safety store and self-
administer his/her medications.
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POLICY: Medication Records
Records of medications are maintained.
Procedure
1. A record of all medication brought into the community is maintained for
three years.
2. A record of medications that are disposed of in the community is
maintained for at least 3 years.
3. Written physician orders for all medications are maintained in the
resident’s chart in the “Physician Orders” section.
4. Medication Administration Records (MARs) are maintained for all
medications poured and/or passed by community staff.
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POLICY: Telephone Orders
Telephone orders for medications are not permitted. Prescribers will be asked to
fax orders directly to the community.
Procedure
1. If a physician or other authorized prescriber attempts to give a telephone
order, he/she is asked to fax the order to the community.
2. Community staff may write the order on the appropriate form and fax it to
the prescriber for a signature.
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POLICY: Medication Labels
Community staff does not alter prescription labels.
Procedure
1. Community staff does not alter prescription labels. In order to maintain a
label that matches the current physician’s order, the designated staff
person:
a. Without obscuring the original label, flags the container with a
brightly colored sticker and writes on it “order changed,” with the
date, time, and his/her initials.
b. The Director of Wellness highlights the old order in the MAR and
writes: “order changed,” with the date, time, and his/her initials.
c. The Director of Wellness transcribes the new order in the next
available space in the resident’s MAR.
2. The Director of Wellness discusses the change with resident and/or
responsible party.
3. The Director of Wellness ensures the new medication instructions are
transmitted to the pharmacy so consecutive refills are appropriately
labeled.
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POLICY: Resident Arrives with a Medication
When a resident arrives at the community with a new medication, steps will be
taken to ensure proper storage and handling of the medication. Physician’s
orders will be verified for all medications.
Procedure
1. Each physician is contacted to ensure that the physician is aware of all
medications currently taken by the resident.
2. Containers are inspected by a pharmacist to ensure the labeling is
accurate.
3. The Wellness Director discusses medications with the resident or the
responsible party.
4. If the physician and Wellness Director agree that the resident is capable of
self-storage and self-administration of medication, the resident’s
medications are stored in a locked compartment in his/her room.
5. The medications are placed in the medication room in an appropriately
labeled drawer, bin, etc., if central storage is required.
6. The medications are appropriately listed on the MAR, verifying accuracy
according to physician orders.
7. All medications not self-stored or self-administered by the resident are
logged on to the Centrally Stored Medication Record.
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POLICY: Medication Refills
Medication refills will be obtained in a timely manner to ensure residents have all
physician ordered medication available.
Procedure
1. The Director of Wellness contacts the dispensing pharmacy to obtain a
refill at least seven (7) days prior to running out of a medication, unless
medication is on a cycle refill with the pharmacy. When the medication is
ordered it is entered onto the Refill Roster. When medications are
received they are entered on the Refill Roster.
2. If necessary, the prescribing physician is contacted for a new order.
3. Medications are never allowed to run out unless directed to by the
physician (obtain this direction in writing).
4. Containers are inspected to ensure all information on the label is correct.
5. Any changes in instructions and/or medication are noted; for example,
change in dosage, change to generic brand, etc.
6. Medications are logged on the Centrally Stored Medication Record when
received.
7. The Wellness Director discusses any changes in medications with the
resident, responsible party and appropriate staff.
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POLICY: Medications are Permanently Discontinued
Permanently discontinued medication will not be retained in the community.
Procedure
1. The Wellness Director confirms with physician the order to permanently
discontinue the use of the medication, and obtains written documentation
of the discontinuance from the physician, prior to destroying.
2. The Wellness Director discusses the discontinuance with the resident
and/or responsible party.
3. To properly dispose of permanently discontinued medications the
Wellness Director and another adult witness who is not a resident:
a. Returns the medication to the dispensing pharmacy for disposal; or
b. Disposes of the medication in a medical waste receptacle that is picked
up at regular intervals by a licensed medical waste company.
4. Medications to be returned to the pharmacy are held in a bin labeled
“return to pharmacy” in the medication room until the time of pick-up by the
pharmacy.
5. The Wellness Director and witness will document destruction on the
Centrally Stored Medication Record.
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POLICY: Hold Orders
Temporarily discontinued ("dc") and/or “HOLD” medications will be held from use
by the resident as instructed by the physician.
Procedure
1. The Wellness Director discusses the change with the resident and/or
responsible party.
2. The Wellness Director obtains a written order from the physician to HOLD
the medication.
3. Without obscuring the label, the medication container is flagged with a
brightly colored sticker where the Wellness Director writes: “HOLD,” the
date, the time, and his/her initials.
4. The medication is not given to the resident until the date and/or time
indicated in the physician’s hold order.
5. The medication is placed into a plastic bin labeled “On Hold Medications”
in the medication room.
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POLICY: Expired Medications
Expired medication will be not be given to any resident or responsible party, nor
retained in the community.
Procedure
1. Expired medications are not used.
2. The Director of Wellness inspect containers regularly for expiration dates.
3. The Director of Wellness communicates with physician and pharmacy
promptly to obtain a refill.
4. To properly dispose of expired medications the Director of Wellness and
another adult witness who is not a resident:
a. Returns the medication to the dispensing pharmacy for disposal; or
b. Disposes of the medication in a medical waste receptacle, which is
picked up at regular intervals by a licensed medical waste company.
5. The Director of Wellness and witness will document destruction on the
Centrally Stored Medication Record.
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POLICY: Medications Left Behind by a Resident
When a resident moves out of the community, all medications, including over the-
counters, should go with resident when possible.
Procedure
1. If the resident dies, prescription medications are to be destroyed.
2. To properly dispose of medications left behind by a resident, the Director
of Wellness and another adult witness who is not a resident:
a. Returns the medication to the dispensing pharmacy for disposal; or
b. Disposes of the medication in a medical waste receptacle, which is
picked up at regular intervals by a licensed medical waste company.
3. The Director of Wellness and witness will document destruction on the
Centrally Stored Medication Record.
4. Document on Centrally Stored Medication Record when medication is
transferred with the resident. Obtain signature of person accepting the
medications (i.e., responsible party) will be obtained, indicating agreement
with the quantity of each medication transferred out of the community.
5. Medication records are retained for at least three years.
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POLICY: Medication Refusal and/or Missed Doses
No resident will be forced to take any medication. Steps will be taken to avoid
missed or refused doses of medications and related adverse reactions.
Procedure
1. Missed/refused medications are documented in the resident's medication
record and the prescribing physician notified immediately or according to
physician parameters. Physician parameters must be retained in writing
and kept on file.
2. Physician instructions regarding missed dose are followed.
3. The Director of Wellness appraises the resident and contacts the
physician and responsible party if the resident is continually refusing a
medication(s). If unable to resolve continued refusal, the resident’s
relocation from the community may be necessary.
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POLICY: Crushing Medications
Medications will be crushed in accordance with physician’s orders and state
regulations, without infringing on the resident’s personal right to refuse
medications.
Procedure
1. The Director of Wellness obtains a physician’s order prior to crushing a
resident’s medications.
2. The pharmacist is consulted to verify appropriate foods the medication
may be mixed with. This phone conversation is documented in the
resident’s chart.
3. The physician order and documentation of the telephone consult is
maintained in the resident’s record.
4. When crushing medications:
a. A pill-crushing device is used.
b. The completely crushed medication is mixed with an appropriate
soft food such as applesauce or pudding, not a liquid.
5. The resident is clearly informed that he/she is receiving medications.
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POLICY: Transferring Medications for Home Visits
and Outings
Staff will assist resident to obtain/maintain necessary medications for use while
not in the community.
Procedure
1. When a resident leaves the community for a short period of time during
which only one dose of medication is needed, the Director of Wellness
gives the medications to a responsible party in an envelope (or similar
container) labeled with the resident's name, name of medication(s), and
instructions for administering the dose.
2. If the resident is to be gone for more than one dosage period, the Director
of Wellness may:
a. Give the full prescription container to the resident, or responsible
party, or
b. Have the pharmacy fill a separate prescription or separate the
existing prescription into two bottles, or
c. Have the resident's family obtain a separate supply of the
medication for use when the resident visits the family. If family
maintains a separate supply, the Director of Wellness supplies
them with current physician orders prior to every outing or home
visit.
4. The Director of Wellness reviews the resident’s physician orders, appraisal
and service plan to verify the ability of the resident to store and self-
administer medications while away from the community. If it is not safe to
give the medications to the resident, the medications are entrusted to the
person who is escorting the resident off the community premises.
5. The person entrusted with the medications agrees in writing as to the
amount of medication received on behalf of the resident and the
appropriate dosing amount and schedule.
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POLICY: Sample Medications
Sample medications may be used when provided by the prescribing physician.
All safety controls imposed on other medications will apply to sample
medications as well.
Procedure
1. The Director of Wellness ensures that all sample medications received
into the community are provided by the prescribing physician.
2. Sample medications will be labeled with all the information required on any
prescription label except pharmacy name and prescription number.
3. Sample medications are centrally stored, documented and handled in the
same manner as other prescription medications.
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POLICY: Use of Emergency Medications
Residents who have a medical condition requiring the immediate availability of
emergency medication (i.e. nitroglycerine, inhaler, etc.) for life-saving purposes
may maintain the medication in his/her possession if the safety the resident and
other residents can be maintained and state regulatory requirements are
followed.
Procedure
1. A physician order is received stating that the resident is capable of
determining the need for a dosage of the medication and has determined
that possession of the medication by the resident is safe.
2. This determination by the physician is maintained in the individual's file
and available for inspection by the state licensing agency.
3. The physician's determination clearly indicates the dosage and quantity of
medication that should be maintained by the resident.
4. Neither the community Director of Wellness nor state licensing agency
staff has determined that the medications must be centrally stored in the
community due to risks to others or other specified reasons.
5. If the physician has determined it is necessary for a resident to have
medication immediately available in an emergency but has also
determined that possession of the medication by the resident is
dangerous, then that resident may be inappropriately placed and may
require a higher level of care.
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POLICY: Injections
Injectable medications will be administered by authorized licensed nurses or
physicians, according to physician’s orders and state regulatory requirements.
Procedure
1. Injections are administered only by the resident themselves or by a
licensed medical professional. Licensed medical professional includes
Doctors of Medicine (MD), Registered Designated staff persons (RN), and
Licensed Practical/Vocational Nurses (LPN/LVN).
2. Licensed medical professionals administer only medications/insulin that
they have drawn up, or have been pre-drawn by the pharmacy or the drug
manufacturer.
3. If the resident administers his/her own injections, physician verification of
the residents’ ability to do so is maintained in the resident’s record.
4. The Director of Wellness ensures sufficient amounts of medications, test
equipment, syringes, needles, and other supplies are maintained in the
community and stored properly.
5. Syringes and needles are disposed of in a "container for sharps," and the
container shall is kept inaccessible to residents. The container shall be
removed from the community by an appropriate medical waste company.
6. Insulin and other injectable medications are kept in the original containers
until the prescribed single dose is measured into a syringe for immediate
injection.
7. Insulin or other injectable medications may be packaged in pre-measured
doses in individual syringes prepared by a pharmacist or the
manufacturer.
8. Syringes may be pre-filled under the following circumstances:
a. Pre-filled syringes prepared by a registered nurse, may be self-
injected by residents who are able and approved to self-inject.
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b. The registered nurse (RN) must not set up insulin syringes for more
than seven days in advance. The pre-drawn insulin is only for the
resident to self-administer. An LVN may not pre-draw insulin.
9. Injectable medications that require refrigeration must be kept inaccessible
to residents.
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POLICY: Over-the-Counter (OTC) Medications
A physician order is required for all OTC medications.
Procedure
1. OTC preparations are centrally stored, documented and handled in the
same manner as prescription medications.
2. The Director of Wellness contacts the physician for prescriptions for OTC
preparations prior to their use.
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MANAGEMENT
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POLICY: Psychotropic Medications
Psychotropic medications are given in a safe manner according to physician
orders. The community minimizes the use of psychotropic medications when
possible.
Procedure
1. Behavioral and environmental interventions are attempted to avoid over or
unnecessary use of psychotropic medications.
2. Personal Assistants are educated on appropriate interventions for anxiety,
agitation, dementia-related behavioral challenges, and potential adverse
effects of psychotropic medications.
3. The Director of Wellness encourages Personal Assistants to report
adverse effects such as extrapyramidal symptoms and tardive dyskinesia.
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MANAGEMENT
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POLICY: Warfarin and Other Anticoagulants
Residents taking warfarin or other anticoagulants will receive assistance with
necessary monitoring and/or lab tests.
Procedure
1. Residents receiving Coumadin are instructed on signs and symptoms of
complications, and to report these immediately to their physician and to
the Executive Director.
2. Staff are trained on monitoring residents receiving warfarin (Coumadin) or
other anticoagulants.
3. The Executive Director makes arrangements for transportation to lab
appointments as required.
4. Lab results are reported directly to the prescribing physician.
5. The Medication Administration Record is updated immediately upon
receiving the Coumadin dosing change from the prescribing physician.
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MANAGEMENT
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POLICY: Narcotics, Controlled Substances, and
Preventing Drug Diversion
All medications are stored in a secure manner, as outlined in other policies.
Special storage and security procedures will be followed to protect controlled
substances (narcotics, etc.) and to help prevent drug diversion.
Procedure
1. All medications, including over-the-counter medications, are kept in locked
storage at all times.
a. Only authorized staff members are given keys to the medication
storage area.
b. Staff members do not take keys home or otherwise off community
premises.
2. A Narcotic Count Sheet will be maintained for all narcotic medications.
a. When a narcotic is received in the community, it is counted by two
staff members and added to the narcotic sheet with the current
medication count reflected in the amount on hand.
b. Each time a resident receives assistance with self-administration of
a narcotic, this is documented and the amount of medication on
hand is updated on the Narcotic Count Sheet.
c. At the end of each shift, the staff member responsible for
medication completing his/her shift, and the staff member
responsible for medications who is starting his/her shift, count all
narcotic medications and confirm that the amount on hand matches
was it listed on the Narcotic Count Sheet for each medication. Both
staff members will sign a Narcotic Reconciliation Sheet confirm the
accurate count of narcotics on hand.
d. Any discrepancies are immediately reported to the Executive
Director.
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MANAGEMENT
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3. When medications are to be destroyed, the destruction must be witnessed
by the staff member responsible for medications and a pharmacist. The
destruction is documented, including the amount of medication destroyed
and a signature from both witnesses.
4. Staff members will be trained to identify drug diversion and encouraged to
report suspected drug diversion to the Executive Director for proper
investigation.
a. Any drug diversion will be reported to the state licensing agency,
law enforcement, and any other agencies as required.
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Emergencies and
Medical Needs
EMERGENCIES AND MEDICAL NEEDS
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POLICY: Physician and Other Medical Appointments
The resident will receive assistance in obtaining necessary medical care.
Procedure
1. Residents and responsible parties are informed to notify the Wellness
Director of pending physician or other medical appointments.
2. The scheduled physician visits are entered on the physician appointment
calendar.
3. The following accompanies the resident on all physician visits:
a. Physician Visit form.
b. Photocopy of current MAR (originals are never sent).
c. Any other requested documentation (daily glucose reading, etc.).
d. The Physician Visit form is returned to the community and all orders
transcribed by the licensed Executive Director or supervisor on
duty.
4. Family/responsible party may transport the resident to appointments. The
Wellness Director instructs Personal Assistants to have the resident
appropriately dressed and ready for transport.
5. Should the resident not have transportation, the Wellness Director
arranges for necessary transportation.
6. If a resident is unsafe to be left without an escort, the Wellness Director
arranges for a staff member to accompany the resident.
7. Should the Wellness Director determine a resident is not stable, safe, or
comfortable enough for van/car transportation, arrangements are made for
ambulance transport.
8. It will be disclosed to the resident/responsible party upon admission, that
off-hour, unscheduled, or ambulance transportation is the financial
responsibility of the resident.
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POLICY: Labs and Outside Medical Services
The resident will receive assistance with arrangements for outside medical
services.
Procedure
1. Residents and responsible parties are informed to notify the Wellness
Director of any pending outside medical services.
2. The scheduled service is calendared.
3. Should the resident not have transportation, the Wellness Director
arranges for a staff member to accompany the resident.
4. If the resident is unable to be left without an escort, the Wellness Director
arranges for a staff member to accompany the resident.
5. It is disclosed to the resident and responsible party upon admission, that
off hour unscheduled or ambulance transportation is the financial
responsibility of the resident.
6. The Wellness Director instructs all labs reporting or transmitting values to
directly transmit to the physician. Unlicensed Personal Assistants may not
take verbal lab values.
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POLICY: Licensure of Nursing Personnel
Nursing personnel must present verification of such license prior to or upon
employment.
Procedure
1. At the time of employment, nursing personnel who require a license or
registration present verification of such license to the Executive Director.
2. A copy of the current license and registration number is filed in the
employee’s personnel record.
3. A copy of the annual renewal (as applicable) is presented to the Executive
Director.
4. If the validity or standing of a license is in question, the Executive Director
will contact the appropriate board for verification.
5. Until the license is verified, the nurse will not perform any duties requiring
licensure.
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POLICY: Medical Emergencies
The resident will receive emergency medical care when needed to prevent
further injury or illness.
Procedure
1. Personal Assistants immediately summon the community Wellness
Director should a resident exhibit signs and symptoms of a medical
emergency.
2. The Wellness Director makes a determination as to the severity of the
situation.
3. The community summons emergency medical services by calling 911),
when the resident exhibits signs and systems of distress and/or
emergency condition. Examples include, but are not limited to:
a. New onset of chest pain;
b. Recurrent chest pain, unrelieved in 15 minutes by previously
ordered nitroglycerin given as ordered;
c. Unconsciousness;
d. Fall with deformity, severe pain or head injury;
e. Uncontrolled bleeding;
f. First time seizure;
g. Recurring seizure which last for more than 1 minute;
h. Sudden onset severe pain;
i. Shortness of breath;
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j. Sudden lack of muscle control, ability to communicate, drooping
facial expression or other signs of stroke;
k. Low blood sugar (according to physician order parameters, usually
<60);
l. Excessively high blood sugar, according to physician order
parameters;
m. Poisoning;
n. Fever which is not lowering despite interventions and fever
reducing agents;
o. Choking;
p. Psychiatric crisis.
4. A non-emergency transport is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding, etc.
5. The Wellness Director contacts the family/responsible party, as quickly as
possible, once the resident is safely under the care of the paramedics.
Unless instructed otherwise by the family/responsible party, this includes
anytime, 24-hours a day.
6. The Wellness Director or Personal Assistants are not required to obtain
permission from the family/responsible party before summoning
emergency medical services.
7. A staff member remains with the resident until paramedics transport out of
the community.
8. A copy of the current MAR is given to the paramedics, along with the
Emergency Identification Form.
9. The actual medications are retained in the community.
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10. The staff person observing the transport out of the community will note
what belongings are going with the resident, such as jewelry, dentures,
prosthetic devices, etc.
11. A narrative chart entry is made in the resident’s chart regarding the
circumstances which led up to the call (Data), what care was provided by
the staff, including any first aid (Action), as well as the resident’s response
to the action (Response).
12. An Incident Report is completed.
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POLICY: Psychiatric Emergencies
Appropriate care will be arranged for should a resident be in psychiatric crisis.
Procedure
1. Personal Assistants immediately report to the Wellness Director any
significant change in resident affect, personality, or behavior.
2. Any verbalization of suicidal ideation are taken seriously by Personal
Assistants and reported to the Wellness Director.
1. NOTE: Should an Wellness Director not be on duty, suicidal ideations
would be reported to the immediate supervisor or medical professional.
2. Should a resident show evidence of violence (e.g. throwing objects,
attempting to strike another resident, etc.) other residents are immediately
removed from the area and assistance is summoned. Objects that could
be used as a weapon are removed from the area.
3. Physical force is not used to subdue a resident.
4. If the severe behavior continues, call 911. Monitor the resident until
assistance arrives.
5. An Incident Report is completed for all psychiatric crises and given to the
Wellness Director.
6. All psychiatric crises are reported to the resident’s responsible party.
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POLICY: Falls
Should a resident experience a fall, staff will provide or arrange for necessary
emergency care, and will follow up with necessary service plan updates.
Procedure
1. Should the resident have trauma resulting in deformity, exhibit any change
in level of consciousness, received obvious head or significant trauma the
Wellness Director or Personal Assistants summon emergency medical
services (call 911).
2. When a resident falls Personal Assistants are instructed to summon
immediate assistance from the Wellness Director or Nurse Assistant.
3. Personal Assistants do not move the resident, except to protect against
further injury, as in the case of a dangerous environment.
4. The physician is contacted for further instructions if the head was not
involved in the fall and the resident is able to move all extremities.
a. The Wellness Director instructs Personal Assistants to provide
appropriate care and frequent resident checks. Any change in
status is reported to the Executive Director.
5. An incident report is completed.
6. The Wellness Director informs the physician of subsequent falls and
instability. Medical intervention, physical therapy, and/or gait analysis is
arranged when residents remain a significant risk for falls.
7. Ongoing falls may require relocation from the community.
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POLICY: Death of a Resident
The community will take appropriate action in the event of the death of a
resident.
Procedure
1. Call 911. Emergency Medical Services must be summoned to determine
death, unless a hospice nurse is present at the bedside.
2. Do not move the body. The body may not be moved until there is either
coroner release of the body or the police or sheriff on-site gives direct
explicit permission to move the body. Staff should remain with the body at
all times until paramedics arrive.
3. Notify the resident’s primary physician.
4. Notify the Executive Director.
5. The coroner must be contacted. Once paramedics have pronounced the
body (via communication with the physician or coroner), coroner release of
the body must be obtained, allowing for transport to the funeral home of
the resident or family’s choice.
6. Notify the family. Once the body has been pronounced the family may be
told of the death. Frequently the physician will make this phone call.
Otherwise, the Executive Director or the Wellness Director will notify the
family.
7. Prepare the room for visitors if required. Occasionally family or significant
other will want to spend a few moments with the resident prior to transport
out of the community. In consideration, tidy the room, remove linens, etc.,
with objectionable odors and put a chair near the bed. Lights should be
turned on to a comfortable level. Insert the resident’s dentures (if
applicable), close the resident’s mouth and eyes.
8. Contact the funeral home. Once coroner release has been obtained, the
resident may be removed from the community. Call the funeral home
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designated. The resident should remain no longer than two hours in the
community, if possible.
9. Document appropriately.
10. Submit a death report to the state licensing agency.
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POLICY: Elopement/Missing Resident
Elopement precautions and response procedures are carried out for resident
safety.
Procedure
1. ELOPEMENT DRILLS
a. Elopement drills are conducted a minimum of twice per year and
documented accordingly.
2. MISSING PERSON – GENERAL PROCEDURE
a. Local contact numbers of bus, rail, cab or other modes of
transportation will be maintained for possible contact in emergency
search.
b. Staff shall remain alert and follow re-direction techniques if a
wandering resident gains access to any exit areas.
c. Staff shall request help if wandering resident cannot be redirected
easily.
d. In house transportation staff will be notified of potential elopers
possibly seeking rides and advised to be observant for wandering
confused residents.
e. Staff will be routinely alerted by the Wellness Director of residents
identified to be at risk
f. Service plans will reflect interventions for resident safety
g. Routine safety checks will be made by staff.
h. Flashlights and emergency first aid kits will be included in
emergency supplies to accommodate searches outside
i. Walkie-talkie and cell phones are made available during outside
searches
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3. MISSING RESIDENT
a. Staff alerts immediate supervisor to begin a thorough search of
entire community area. This includes searching bathroom areas,
bedroom closets, under beds and window areas to ensure windows
were not used as exit.
b. Executive Director is immediately notified.
c. The Executive Director or designee alerts other departments to
ensure entire community is on alert.
d. A thorough re-search of building including stairwells, roofs,
basements and outdoor area is expanded with ancillary staff and
any volunteers.
e. Automobile searches by staff & volunteers are conducted in
surrounding neighborhood.
f. All search staff call or report back to community regarding status
within 15 minutes.
4. IF RESIDENT IS STILL MISSING
a. Notify sheriff /police department by calling 911 .
b. Provide local law enforcement with the following:
i. Resident full bodied photo
ii. Description of current clothing he/she was wearing
iii. Any other physically identifying information
iv. Information in regard to current medication/treatment needs
v. Information in regard to resident’s nickname or typical
behavior
c. Notify the resident's responsible party.
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d. Continue search efforts per direction of law enforcement.
5. MISSING PERSON – IF RESIDENT IS FOUND
a. Notify all searching parties.
b. Conduct assessment to identify possible injuries.
c. Transfer to hospital for further medical evaluation.
d. Notify physician.
e. Notify the resident's responsible party.
f. Complete an incident report and notify licensing agency per
licensing requirement.
6. MISSING PERSON – WHEN RESIDENT RETURNS TO COMMUNITY
a. Obtain updated medical evaluation from hospital or doctors office.
Initiate any new orders.
b. Establish private duty care for resident oversight until resident re-
assessment indicates there is no longer a need.
c. Maintain resident behavior monitoring for identification of any
triggers.
d. Complete resident record documentation.
e. Update service plan and resident summary to reflect potential
elopement.
f. In-service care staff and any relevant staff members.
g. Evaluate the community’s continued ability to meet the resident’s
needs
h. Responsible party will be kept informed and assisted with
alternative placement if determined to be necessary
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POLICY: Advance Directives
Residents may have Advance Directives and/or Do-Not-Resuscitate (DNR)
orders. The community staff will take steps to ensure, as best as possible, that a
resident's wishes are honored.
Procedure
1. A Do-Not-Resuscitate order does not direct health professionals working
in the community or any staff member to withhold all emergency care.
The resident should receive all medications, treatments and any other
care as ordered by the physician, as well as all emergency first aid care as
necessary. Any necessary transfer to a higher level of care (acute
hospitalization) should take place as necessary.
2. This policy shall at all times be available for review by the licensing agency
and its representatives.
3. A resident requesting a Do-Not Resuscitate order be implemented will be
directed to obtain the directive from their visiting home health nurse or
physician. No agent or employee of the community shall sign, witness or
be legally recognized as a surrogate decision maker for the resident’s Do
Not-Resuscitate order.
4. A copy of the Do-Not-Resuscitate order will be placed in the resident’s file
and in their room. Note: this is confidential information and must not be
posted in a conspicuous place for visitors or other residents to see.
5. A list of all residents with a current valid Do-Not-Resuscitate order will be
available in the following locations:
a. _____________________________________________________
b. _____________________________________________________
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c. _____________________________________________________
6. Should a resident desire, a medic-alert bracelet with a DNR medallion may
be ordered and worn by the resident with a current Do-Not Resuscitate
status.
7. In the event of a crisis, emergency medical services should be
immediately summoned for the resident. When the emergency medical
service personnel arrive they should immediately be presented with the
resident’s Do-Not-Resuscitate order.
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VANTAGE POINTE VILLAGE
POLICY AND PROCEDURE
MANUAL
Documentation
and
Forms
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POLICY: Confidentiality
All resident data and information is treated as confidential.
Procedure
1. Resident charts, information, preadmission documentation, etc., are kept
inaccessible to visitors and individuals not involved in the direct care and
admission of the resident.
2. Care and administrative staff given access to resident related
documentation are trained during orientation to maintain confidentiality.
3. Photocopying and removal of resident information is strictly prohibited
unless approved by the Executive Director.
4. Release of resident health and personal information is made:
a. When requested by the competent resident.
b. When requested by the resident’s conservator as allowed
according to law.
c. After consent for release of information is signed by either party
above.
5. State regulatory personnel as allowed under regulation may review
resident information.
6. The ombudsman is provided the name of the resident, name and address
of the responsible party and room number of each resident upon request.
7. Medication and other clinical information are provided only upon release
by the resident or conservator, as appropriate.
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POLICY: Narrative Charting Entries
Narrative charting will be maintained to promote clear communication regarding
resident care.
Procedure
1. The format for narrative charting is:
a. D = Data
Enter all essential facts related to resident status.
b. A = Action
State the actions/interventions made in response to the data.
c. R = Response
Follow up and document the resident’s response to the action
taken.
2. A narrative entry is made upon admission, noting the date and time of
admission, and any pertinent data regarding the resident’s response to
their placement.
3. A narrative entry addressing current resident status is made every shift (or
more often if necessary) for 48 hours after a fall or sentinel event.
4. Except as stated in (2) and (3) above, staff utilize the charting by
exception related to resident status.
5. The Wellness Director reviews the narrative charting from the previous
shift, for at risk residents.
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POLICY: Incident Reports
Injury and unusual incidents will be reported in compliance with state regulatory
requirements.
Procedure
1. The Unusual Incident form is used to document and report any incident
which is a threat to a resident’s health, safety, welfare, or rights. This
includes, but is not limited to occurrences such as:
a. Falls.
b. Injury.
c. Psychiatric crisis.
d. Unexplained absence.
e. Any violation of resident rights.
f. Any incident that threatens the health, welfare, or safety of the
resident.
2. Any incident which is a threat to a resident’s health, safety, welfare, or
right will be reported to the state licensing agency within 7 days of the
incident and a report made via telephone within 24 hours of the incident.
3. The Wellness Director completes incident reports.
4. Incidents are reported to the resident's responsible party. Document the
date and time the report was made to the family/responsible party in the
narrative charting section.
5. All incidents related to physical abuse, neglect, sexual assault, or
exploitation are reported to the ombudsman, state licensing agency, and
in the case of assault (physical or sexual) to law enforcement.
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POLICY: Abbreviations
Standardization of terms, definitions, abbreviations, acronyms, and symbols will
be used to promote clear communication and accuracy of information.
Procedure
1. A standardized list of acceptable terms, abbreviations and acronyms is
posted in each community charting area.
2. All staff are instructed to use only approved terms, abbreviations, and
acronyms on this list for all charting.
3. Changes or additions to the list of acceptable terms are made after
approval from the Executive Director and Wellness Director.
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POLICY: Approved Abbreviations
ALWAYS follow community policies regarding the use of abbreviations. Never
“invent” a new abbreviation.
Remember, it is best to write words out and avoid the use of abbreviations.
Medical professionals working with Vantage Pointe Village communities should
be encouraged to avoid the use of abbreviations. Never guess at the meaning
of an abbreviation; verify the meaning with the author.
A
a Before
ABD Abdomen
AC Before eating
AD Right dear
ad lib As desired
ADL Activity of daily living
am Morning
amb Ambulate
AS Left ear
ASAP As soon as possible
AU Both ears
B
BID Twice a day
BKA Below the knee amputation
BM Bowel movement
BP or B/P Blood pressure
BPM Beats per minute
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BS Bowel or breath sounds
C
c With
C Celsius or centigrade
C&S Culture and sensitivity
CA Cancer
Ca Calcium
CAD Coronary artery disease
CAP Capsule
CAT Computerized axial tomography, as in "CAT scan"
CBC Complete blood count
CBG Capillary blood gas
CCU Clean catch urine
CHF Congestive heart failure
CNA Certified nurse’s aide
CNS Central nervous system
C/O Complaining of
COPD Chronic obstructive pulmonary disease
CPAP Continuous positive airway pressure, as in "CPAP machine"
CPR Cardiopulmonary resuscitation
CSF Cerebrospinal fluid
CT Computerized tomography, as in "CT scan"
CVA Cerebrovascular accident, aka "stroke"
CXR Chest X-ray
D
DAT Diet as tolerated
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DC Discontinue or discharge
DM Diabetes mellitus
DNR Do not resuscitate
DME Durable medical equipment
DOB Date of birth
DPT Diphtheria, pertussis, tetanus
DVT Deep venous thrombosis or deep vein thrombosis
DX or Dx Diagnosis
E
ECG Electrocardiogram
ECT Electroconvulsive therapy
ED Executive director
EMS Emergency medical services
ENT Ears, nose, and throat
ETOH Ethanol, often used in reference to alcohol use/abuse
F
F Fahrenheit
FBS Fasting blood sugar
Fe Iron
FTT Failure to thrive
FU Follow-up
FWB Full weight bearing
FWW Front wheeled walker
Fx Fracture
G
GI Gastrointestinal
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gr Grain, 1 grain = 65 mg
gm Gram
gt or gtt Drops
GU Genitourinary
H
H Hour
H2O Water
HA Headache
HDL High density lipoprotein
Hgb Hemoglobin
HO History of
HOB Head of bead
HOH Hard of hearing
HR Heart rate
HS At bedtime
HTN Hypertension
Hx History
I
I&O Intake and output
ID Identification
IDDM Insulin dependent diabetes mellitus
IM Intramuscular
INR International Normalized Ratio
IPPB Intermittent positive pressure breathing
IV Intravenous
L
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L Left or Liter
LOC Loss of consciousness or level of consciousness
LPN Licensed practical nurse
LVN Licensed vocational nurse, this term is used only in California and
Texas
M
mL Milliliter
MRI Magnetic resonance imaging
MRSA Methicillin resistant staph aureus
MS Multiple sclerosis
N
Na Sodium
NAS No added salt
NG Nasogastric
NKA No known allergies
NKDA No known drug allergies
noc Nighttime
NPO Nothing by mouth
NS Normal saline
NSAID Non-steroidal anti-inflammatory drugs
NT Nasotracheal
N/V Nausea and vomiting
NVD Nausea, vomiting, and diarrhea
O
OD Right eye
OOB Out of bed
OS Left eye
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OTC Over-the-counter
OU Both eyes
oz Ounce
P
p After
PC After meals
PDR Physicians' desk reference
pm Afternoon
PO By mouth
PRN As needed
PT Physical therapy or Prothrombin time
Q
Q Every (e.g., Q6H = every 6 hours)
QD Every day
QH Every hour
Q4h, Q6H,
etc...
Every 4 hours, every 6 hours, etc...
QID Four times a day
QNS Quantity not sufficient
QOD Every other day
R
R Right
RBC Red blood cell
RDA Recommended daily allowance
R/O Rule out
ROM Range of motion
RT Respiratory therapy
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Rx Treatment
S
s Without
SL Sublingual
SNF Skilled nursing facility
S/O Significant other
SOB Shortness of breath
STAT Immediately
Subq or
SQ
Subcutaneous
Sx Symptoms
T
TB Tuberculosis
Temp Temperature
TIA Transient ischemic attack
TID Three times a day
TO Telephone order
Tx Treatment
U
UA Urinalysis
URI Upper respiratory infection
US Ultrasound
UTI Urinary tract infection
V W X Y Z
VO Verbal order
VRE Vancomycin-resistant enterococcus
WBC White blood cell or count