Hey ActivityGal.. the main focus on the New Guidelines is to bring your facility, your staff, together and create a more community like care facility. They would like everyone in the facility to get to know the residents in the same way you and your staff do. You have the ms.Jones who always helps out at bingo, the two that always fight, the ones that sneak food, mr.Brady that was in the war, lots of war stories, lots of family, the ones that sit by the door and wait for family that never come. They would like the entire facilty to participate in helping each and every resident to feel less like a nursing facility and more like a retirement community, decrease the stress and depression, less transition shock for home to nursing, decrease the loss of life roles stress, embrace each resident more like a person.. develope Person Appropriate Care.
Where in the past the nurses aides would not engage the residents for fear the DON would gripe.. the New Guidelines direct your entire facilty to report and document any extra activity, any requests, any self set goals (i.e. resident would like to write family or would like to practice walking after surgery) these should be documented and added to a progress note, an updating assessment, wound into the careplan, social services should be brought in..
We have developed a series of forms in our FTag Course to help with the reporting and documentation,
One: Extended Assessment Form to add new interests, (i.e. Ms. Jones has express the want to write letters to home, add this to your assessment that she likes to write letter, send cards, contact family about supplies, provide supplies, make use of the nurses aide or a volunteer if she cannot write, include in a letter writing club if she can )
Second: Multi Dept Participation Form to document any off calendar activity, some facilities are making these forms available at the AD Office, In and Out box, some on a floating clip-board, some have a clip-board at each dept station, dietary, maintenance, nursing, admin, receptionist, some are keeping the records in a folder on the back of a closet door. These forms will help the AD (community cooridnator) to document and to update assessments to further direct Person Appropriate Care, Ms Jones would like a radio, collects dolls, likes cards.
We have been consulting ADs to FIRST start on the gathering of information, extend assessements, document new interest and self set goals. Conduct InService sessions to redirect and inform facility staff on the new direction of Person Appropriate care, and full facility involvement, include instructions on any new techniques in documentation and forms. Once you start this new direction you careplans will shift to a more person appropriate verbage.
Concern. Ms Jones will need to maintain cognitive levels, she has expressed a self-set goal to communicate with family more through mail which will increase her activity and abilities.
Strategy&Goal. Encourge and involve Ms Jones in group activities cards, collecting groups, setup and take down of activities, contact family for radio, letter writing supplies, family mailing addresses, instruct Nursing Aides, AD Staff, Volunteers to encourage, challenge and to help with writing letters, Inform ms Jones of opportunities to assist with parties, entertainment, she has expressed the want to be helpful, retired teacher.
This is kind of a drawn out careplan just to give you an idea of the direction you need to be moving. The Concerns/Problems, the Strategies and Goals will all be pretty much the same therapies as always, it will be the facility involvement and Person Appropriate approch that will change.. The Third Form we have developed in our Ftag Course is a NonSchedule Participation Summary to help document the off calendar activity. From the example above.. it would be impossible to cover the range of participation incluced in the Careplan, this is where the MultiDept Particpation Records and a Extended Participation Summary will help you to document Faciltity wide activity, by you, your staff, facility staff, volunteers, familty members .. all of the combined efforts of everyone, documented, will satifiy state, that you and your facilty did indeed meet your CarePlan Goals..
Hope this helps, it is just an example, but it will give you an idea of where you need to be heading..