Random observations about long-term care

By Michael C. LaFerney | 05/05/2015

Do you agree?

As a clinical nurse specialist in nursing homes, I often observe nursing routines and procedures. Several observations stand out in my mind.
Infection control doesn’t seem to have the same emphasis it once had, and I can’t help but correlate my observation with today’s high rate of infection. The main infections I see in long-term care are MRSA, C. diff, urinary tract, and respiratory. I see caregivers doing less hand washing between patients, more ducking in and out of patient rooms without stopping to gown and mask, and over-relying on antiseptic hand lotions. Close quartering of patients, understaffing, and lack of training, along with comorbidity and advanced age of residents, are all factors that lead to infection.
Many nursing homes, however, do not have a staff member who is assigned specifically to infection control. Instead, this important responsibility is often assigned as an additional duty to someone such as the assistant director of nursing or a staff development nurse. It is time for long-term care to give infection control the priority it once had. Although administrators are under pressure to reduce costs, an effective infection-control nurse can reduce the tremendous costs that patient infection entails.
LaFerney_Michael_embed_SFWAnother nursing practice that has less priority today than in the past is the shift-to-shift report. Because of staffing issues and varying hours of work, it is rare that all team members are present for such communication. I see the day nurse giving a short report to the evening nurse but without certified nursing assistants (CNA) present. I will, on the other hand, see a CNA giving a report to a CNA who is coming on. The advantage of giving a report where all staff members are present is that they will all be on the same page with regard to care.
In addition to contributing to team spirit, shared input enhances problem-solving and planning. Questions such as “Who is responsible for the code cart in an emergency?” and “How do we stick together to deal with Ms. Jones’ manipulative behaviors?” may be addressed at this time with input from all. This can also be a time for nurse leaders to educate staff members about changes in patient status and treatment or better ways to deal with patients. Without this team encounter, a lot of information must be learned or passed on in a piecemeal fashion, which is more time-consuming and less efficient.
The switch to computerized records will eventually lead to better care and safety, but I am seeing instances where the programs are instituted too quickly and without the training needed. This leads to stressed-out nurses, poorer care, and more errors. Often, ancillary staff members are left out. At one nursing home I go to, nursing notes are now put into the computer. Although I rely on and value these observations while conducting my assessments, I could not access the notes because I was not trained in the system and had not been assigned a password. This has since been corrected. This was an oversight, but if patient charts are electronic, all clinicians need to have access that doesn’t compromise confidentiality and security.
My final observations have to do with my role as a clinical nurse specialist. I, along with many other authors, have written articles about the dangers of antipsychotic medications for nursing home residents. Many nursing homes now have behavior rounds where dosage reductions of medications are discussed with nursing, medical, and social-work staff members. This can be an effective tool, but I am seeing some downsides, including discontinuing medications completely rather than reducing them gradually. If medication is abruptly stopped, patients on antidepressants can experience discontinuation syndromes that result in rebounding of depression, symptoms of panic, electric shock feelings, weepiness, and mood lability. Antianxiety meds must be slowly tapered, as seizures, rebound anxiety, and agitation can occur.
Another troubling observation is what I see as an increasing perception by caregivers that antipsychotics have no role at all. For example, I may see a patient who is psychotic, hearing voices, hallucinating, and agitated and will note that an antidepressant such as trazodone (Desyrel) has been tried or suggested. This type of medication, however, will not reduce paranoia, nor will it eliminate or reduce hallucinations. Only an antipsychotic will do that.
Guidelines that recommend avoidance of antipsychotic meds are intended for patients with dementia, as these medications are not that effective for that population and have a black box warning. There are some cases, however, where they might be needed, and the risk versus benefit must be assessed. Some nursing home personnel, in their zeal to cut antipsychotics, are reducing the use of antipsychotic medication for patients with schizophrenia, which can lead to serious decompensating.
I don’t want to generalize what I have observed to all nursing facilities, but these are some of my observations. Do you agree with me or not? Perhaps you have insights on these issues that I have missed. Your perspectives are important, and I encourage you to share them with other nurses. The goal is to improve patient care and nursing performance, and I know we agree on that! 
Michael C. LaFerney,PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.
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