MEDICATIONS
Why is it important to document PRN effectiveness after administration?
To show whether the medication helped the resident
What documents the resident’s diagnosis, goals and outcomes, level of assistance with ADLs, safety concerns, behaviors, preferences, routines, mobility status, dining needs, toileting needs, interventions, and instructions for care staff.
Service Plan (Care Plan)
Where should you document that a resident was showered?
The shower schedule.
Keeping consistent routines helps reduce this in memory care residents.
Confusion, anxiety, and agitation
This should always be within reach of the resident to reduce fall risk
Resident's walker
What should you do if a resident refuses their medication?
Must try at least 3x.
(Try change of face.)
(Crush medications and put in food or pudding)
If still refuses, document refusal in Emar and notify physician using Missed Med form.
Who updates the Service Plans?
The Wellness Director.
Where should you document all verbal communications with families, guardians, pharmacy, and physicians?
Progress note
What should care staff do first if a resident becomes aggressive during care?
What is step away, create space, and allow the resident time to calm down if it is safe to do so?
How often should Wellness checks be done?
At least every 2 hours. (4x per shift)
Some residents require 1 hour checks (8x per shift)
What are the 6 rights of medication?
Right resident
Right medication
Right dose
Right time
Right route
Right documentation
Who is responsible for completing a Change of Condition assessment?
What is the Wellness Nurse or licensed nurse?
Why is Alert Charting important?
This helps staff track a resident with a change of condition, temporary medical problem, or behavioral concern.
What should you do if a resident refuses a shower?
Document ® next to resident name, and write in the resident’s name for the next day.
Med-Tech are to document in a prog note for resident refusal including reason and at least 3 attempts made to complete the task.
What are wellness checks (rounds) for?
What is helping staff monitor resident safety, address needs for ADLs, and overall wellbeing?
What should you do if a medication has not been filled by pharmacy and the resident is almost out?
Notify the Wellness Team.
Call the pharmacy immediately and try to get the medication STAT. (Document communication with pharmacy in the prog notes)
Where should ISP's be kept at all times?
The Service plan binder in the Laundry room.
Documentation should be timely, Accurate and _____.
(What kind of documenting should be avoided?)
Objective
(charting opinions or assumptions)
If a resident repeatedly tries to stand up without assistance, what could this mean?
The resident may need toileting, pain relief, repositioning, or another unmet need addressed.
When a resident reports hitting their head during a fall, this is the immediate next step
Call 911!
What medication require as needed by and at least 3 interventions attempted before administration.
PRN psychotropic medications
How often are resident's Service plans updated?
Quarterly (Unless they have a Change Of Condition)
These things should be documented before and after PRN medications given for behaviors.
What are triggers, interventions used, and effectiveness of the medication?
A resident starts coughing more during meals and holding food in their mouth and suddenly spits out medications. What is the main safety concern?
What is aspiration risk?
A resident repeatedly attempts to stand without assistance despite being a high fall risk. What intervention may help reduce future falls?
What are increased wellness checks, redirection, and ensuring mobility aids are within reach