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Morningside House

Standards of Care
Interim February 13, 2008
TABLE OF CONTENTS

Page #
Activities...........................................................................................................3
ADL: Dressing and Hygiene............................................................................3
ADL: Mobility/ROM Contracture....................................................................4
ADL: Elimination............................................................................................4
ADL: Oral Hygiene..........................................................................................4
Advance Directives...........................................................................................5
Communication With Resident.....................................................................5, 6
Communication With Cognitively Impaired Resident.....................................6
Discharge Planning.......................................................................................6, 7
Escorted/Unescorted Day Pass/Overnight
Therapeutic Leave of Absence.......................................................................7
Medical Condition: Dialysis........................................................................7, 8
Medical Condition: Seizure Disorder...............................................................8
Medications: Psychotropic Drug Use...............................................................8
Medications: Self-Medication..........................................................................9
Nutrition/Hydration..........................................................................................9
Pain ............................................................................................................9, 10
Palliative Care/End of Life Care Plan/Hospice..............................................10
Psychosocial Needs: Potential for Verbal or Physical Aggression.................11
Psychosocial Well-Being ...............................................................................11
Safe Swallowing.............................................................................................12
Safety: At Risk for Elopement .......................................................................12
Safety: Oxygen Use........................................................................................13
Safety: Risk for Falls.....................................................................................13
Skin Integrity: Actual Skin Breakdown..........................................................14
Skin Integrity: At Risk for Skin Breakdown...................................................14
Sleep...............................................................................................................14
Spirituality Care Plan................................................................................14, 15
Tube Feeding..................................................................................................15

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ACTIVITIES

Intervention Responsible Discipline


Assess preference in leisure activities and encourage Activities
residents to express and participate in their preferred activity
Orient to programs of the day; invite and encourage All
participation
Provide materials as needed for independent leisure Activities
interest upon request
Encourage active participation when attending Activities
programs based on comfort and ability
Observe emotional, physical and social response to activities Activities/ Nursing
Refer to "recreation assessment" for interests All

ADL: DRESSING AND HYGIENE

Intervention Responsible Discipline


Provide privacy during dressing and hygiene Nursing
Provide assistance with dressing and hygiene as Nursing
indicated in Routine Care Profile
Provide clean, appropriate clothing and footwear Nursing
Provide desired personal articles (e.g., deodorant, Nursing
toothbrush, soap) within resident's reach
Encourage resident to perform ADL to level of ability Nursing
Encourage independence but assist when resident Nursing
is unable to perform
Establish a routine for self-care Nursing
Monitor cleaning and condition of nails according to Nursing
resident's ability
Refer to podiatrist, as needed Nursing/Medical
Be available for assistance in dressing, as necessary Nursing
Facilitate resident's combing hair, as appropriate Nursing
Facilitate resident's shaving self, as appropriate Nursing
Assist with laces, buttons and zippers, as needed Nursing
Place soiled clothing in laundry; offer to hang up or Nursing
place clean clothing in dresser
Reinforce positively resident's efforts to dress self Nursing
Refer to OT for evaluation as needed

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ADL: MOBILITY/ROM CONTRACTURE

Intervention Responsible Discipline


Encourage and support resident’s All
functioning at highest possible level
through prompting and guiding
Observe for decline/change in function Nursing/PT/OT/Medical
Refer to PT/OT for evaluations as needed PT/OT/Nursing/ Medical
Assist with mobility as indicated on CCP Nursing

ADL: ELIMINATION

Intervention Responsible Discipline


Provide privacy during elimination All
Observe for frequency of urination and bowel Nursing
movements
Observe fluid intake Nursing/Dietary
Provide adequate fiber in diet Nursing/Medical/Dietary
Assist resident to toilet at specified intervals (see Nursing
CCP and/or toileting plan)
Refer to medical provider for bowel/bladder Nursing/Medical
regimen orders as needed

Incontinence
Intervention Responsible Discipline
Evaluate for underlying causes of incontinence Nursing/Medical
Refer to specialist for treatment Nursing
Provide toileting plan that supports resident’s lifestyle and Nursing
voiding pattern Nursing
Utilize appropriate absorbency products Nursing
Toilet resident promptly upon request Nursing
Assist resident in toileting, hygiene and clothing as needed Nursing
Medication as ordered Nursing/Medical
Modify clothing and environment to provide easy Nursing/Rehab
access to toilet
Provide and encourage fluid intake to maintain bladder tone Nursing/Dietary

ADL: ORAL HYGIENE

Intervention Responsible Discipline


Observe oral mucosa weekly Nursing
Assist resident with brushing teeth and rinsing mouth Nursing
according to self-care ability

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ADVANCE DIRECTIVES

Intervention Responsible Discipline


Determine if resident has advance directives upon admission Social Work
Educate resident/family/designated representative on Social Work/Nursing/
Advance Directives MD
Identify legal Health Care Proxy/guardian/designated Social Work
representative
Notify Social Work if resident indicates desire to select/change All
advance directives
Be aware of Advance Directive (healthcare proxy, living will, DNR) All
status of resident
Respect resident’s decision concerning Advance Directives All
Provide written information on Advance Directives Social Work
Review hospital documentation of resident’s
Advance Directives Medical/Nursing/Social Work

COMMUNICATION WITH RESIDENT

Intervention Responsible Discipline


Address by stated name preference in a friendly, All
calm and respectful tone, with eye contact.
Determine interests and desires All
Assist in personalizing environment, clothing, appearance
Assist resident in maintaining dignity of All
clothing, hygiene, and appearance
Provide physical and verbal cues during care All
Caregiver to introduce self by name and role All
Speak with resident while providing care and treatment All
Address resident by name when interacting All
Identify self and purpose of interaction to resident All
when approaching
Approach resident slowly and from the front All

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COMMUNICATION WITH RESIDENT—Continued

Intervention Responsible Discipline


Ask if assistance is needed before providing assistance All
Explain procedures to resident before and during performance All
Be aware of facial expression, body language, and tone All
of voice when approaching resident
Provide a consistent physical environment and daily routine All
Avoid over-stimulation All
Ask questions one at a time All
Limit need for decision-making if frustrating/confusing All
for resident
Give direction and observe for understanding All
Arrange for interpreter through staff, interpreter list or Social Work/Nursing
outside provider
Refer to Speech for evaluation as indicated All

COMMUNICATION WITH COGNITIVELY IMPAIRED RESIDENT

Intervention Responsible Discipline


Identify deficits on ability to communicate All
Recognize frustration and offer support All
Allow more time to respond to communication All
Speak slowly/clearly/using simple words/sentences. All
Encourage resident/staff/family to practice and incorporate All
adaptive techniques into daily communication
Speak directly to and standing in front of resident when speaking. All
Encourage family support All
Arrange for interpreter/alternate means for resident to All
communicate needs, including use of interpreter phone service
Educate resident/staff/family on individualized recommendations All

DISCHARGE PLANING

Intervention Responsible Discipline


Coordination of Discharge Social Work
Assess discharge potential in relation to living situation, All
available support person, financial resources, and resident’s
functional and cognitive status
Addresses issues that may arise as obstacles All
to discharge.

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DISCHARGE PLANING—Continued

Intervention Responsible Discipline


Discuss with resident/designated representative All
(support person) the discharge planning process upon admission,
and at initial, quarterly, and significant change
care plan meetings as appropriate
Invite and encourage resident and designated representative Social Work
(support person) to participate in discharge planning process
Communicate/inform resident/designated representative Social Work/Nursing/OT/PT
(support person) of resident’s progress and
readiness to discharge
Provide education for resident and/or designated All
representative (support person) as needed
Assess appropriateness of placement and discharge potential Social Work
on a quarterly basis

ESCORTED/UNESCORTED DAY PASS/OVERNIGHT


THERAPEUTIC LEAVE OF ABSENCE (TLA)

Intervention Responsible Discipline


Assess resident using criteria in policy and procedure on All
escorted/unescorted day pass and/or Therapeutic
Leave of Absence (TLA)
Obtain physician‘s order written for escorted/unescorted Nursing
day pass/overnight leave of absence if request is granted
Inform resident and/or family of granting/denying Social Work/Nursing
the request and of procedures
Provide written information regarding overnight Social Work
therapeutic leave of absence
Monitor resident for compliance All

MEDICAL CONDITION: DIALYSIS

Intervention Responsible Discipline


Maintain hemodialysis schedule as ordered Nursing/ Medical
Utilize communication book with dialysis unit — Nursing
Alert medical provider of recommendations from Nursing
dialysis unit
Encourage resident to maintain any dietary or fluid Nursing/Dietary
restrictions, as ordered
Observe access site for drainage, bleeding, pain, or Nursing/ Medical
signs/symptoms of infection

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MEDICAL CONDITION: DIALYSIS—Continued

Intervention Responsible Discipline


If access site is bleeding, apply direct pressure and call Nursing
for assistance immediately
Use nonaccess arm for blood pressure Nursing

MEDICAL CONDITION: SEIZURE DISORDER

Intervention Responsible Discipline


Administer anti-seizure medication, as ordered Nursing/ Medical
Monitor scheduled therapeutic drug levels Nursing/ Medical
Observe for signs/symptoms of seizure activity All
Neurology consult, as needed Nursing/ Medical
If resident has seizure activity, do not move them All
Protect them from harm by removing objects in
environment that may harm them, provide airway
support, and notify medical provider

PSYCHOTROPIC DRUG USE

Intervention Responsible Discipline


Maintain calm environment All
Approach calmly All
Provide reassurance prn All
Administer medication as ordered and observe for Nursing/Medical
effectiveness
Observe for adverse effects and effectiveness of medications Nursing/ Medical
Observe for changes in sleep pattern, weight, labs, Nursing/Medical
appetite, behavior, mood, and level of alertness
Observe bowel status Nursing/ Medical
Encourage verbalization of feelings All
Observe orthostatic blood pressure monthly Nursing/ Medical
Medication review periodically for dose Nursing/Medical
appropriateness and for possibility of reduction
Assess for side effects of medications and fall risk Medical/Nursing
Evaluate for non-pharmacologic, behavioral Interventions that All
may decrease the need for medication
Manage any side effects of medications. Medical/Nursing
Akinesia
Dystonia
Tardive dyskinesia

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MEDICATIONS: SELF-MEDICATION

Intervention Responsible Discipline


Assess resident's ability to self-medicate Nursing/Medical
Provide resident medications in locked drawer Nursing
Confirm daily that resident has taken medications and Nursing
record on MAR
Provide resident with new MAR sheet for his or her Nursing
signature weekly or when changes are made in
medication regimen
Collect MAR copy from resident on weekly basis Nursing
Assess self-medication competency on an ongoing basis Nursing/Medical
Educate resident on each of their medications that they Nursing
will be self-administering, including route, frequency,
purpose and side effects. Also instruct on how to remove
medication from vial or blister-pack.

NUTRITION/ HYDRATION/DENTAL

Intervention Responsible Discipline


Provide diet as ordered Dietary/Nursing
Provide nutrition supplement as ordered Dietary/Nursing
Resident will be provided with adequate fluid Dietary/Nursing
Observe for signs/symptoms of aspiration/dehydration/ Dietary/Nursing
vomiting/diarrhea
Monitor stability of weight/labs Dietary/Nursing/ Medical
Observe food/fluid intake for consistent patterns or Dietary/Nursing/ Medical
changes and tolerance to diet
Dental visits yearly and as needed Dietary/Nursing
Provide nutrition as recommended by dietary Dietary/Nursing
Identify residents with food allergies Dietary/Nursing/ Medical
Monitor resident for food/drug interactions Dietary/Nursing/ Medical

PAIN

Intervention Responsible Discipline


Provide pain medications as ordered and evaluate Nursing/ Medical
effectiveness
Provide comfort measures prn All
Control environmental factors influencing resident's All
pain response (e.g., room temperature, lighting, noise)
Observe effectiveness of pain control measure and All
modify if needed.

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PAIN—Continued
Intervention Responsible Discipline
Inform/provide info re: pain management to resident/family. Nursing/Social Work/
Medical
Observe for verbal/nonverbal expressions of pain. All
Encourage resident to inform staff of any changes in frequency, All
intensity and/or pain site (if able).
Provide non pharmacologic/holistic Interventions. RT/Social Work/Dietary
Pain is whatever the resident indicates All

PALLIATIVE CARE/END OF LIFE CARE PLAN/HOSPICE

Intervention Responsible Discipline


Discuss with resident and/or Health Care Agent/ family All
the goal of care
Encourage resident to participate as able in decision making All
about plan of care
Review health care wishes/advance directives Social Work/Nursing/
Medical
Inform family/friend of resident’s choices for Social Work/Nursing/
care and treatment. Medical
Address resident/family’s questions, feelings and response All
to illness
Provide for residents comfort, companionship, emotional/physical All
and spiritual needs
Inform and encourage family to participate in resident’s plan of care All
Provide family/friends with comfort measures: nourishment All
emotional and spiritual support, and counseling
Observe resident for verbal/non verbal expressions of pain All
Educate resident and/or family and staff on issues related to All
death/dying process
Provide comfort measures and pain relief Nursing/Social Work/RT/
Medical

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PSYCHOSOCIAL NEEDS:
POTENTIAL FOR VERBAL OR PHYSICAL AGGRESSION

Intervention Responsible Discipline


Observe resident for interactions with other All
residents, visitors and staff
Remove and redirect the resident from the situation if resident
initiates verbal or physical aggression towards another person All
Refer for team meeting if change in behavior status is All
observed
Refer for psychology/psychiatry evaluation if needed Nursing/Medical/
Social Work
Assist resident in identifying and using appropriate All
expressions of anger or frustration
Limit access to frustrating situations until resident is All
able to express anger appropriately
Instruct resident to seek staff assistance during periods All
of increased tension
Provide feedback on behavior to help resident to All
identify anger
Establish expectation that resident can control his/her All
behavior
Instruct on use of calming measures such as deep breaths All
Provide positive reinforcement for appropriate All
expression of anger

PSYCHOSOCIAL WELL-BEING

Intervention Responsible Discipline


Orient and introduce resident to environment, staff and All
programs
Encourage resident to express feelings/thoughts in Social Work, Nursing
response to placement, change in life status, change in
caregivers, environment and routine
Observe for adjustment All
Invite and encourage resident and/or designated representative Social Work
to be involved and participate in plan of care.
Ongoing assessment for appropriateness of placement/discharge Social Work
potential
Invite family and friends to visit and encourage their support. All
Support resident’s ability to cope with changes in new environment All

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SAFE SWALLOWING

Intervention Responsible Discipline


Ensure that resident is seated in a fully upright Nursing
position as close to ninety degrees as possible during
and for thirty minutes after meals
Refer to MD for evaluation Nursing/Medical
Refer to OT department for speech screenings, Nursing/ Medical
evaluations or training as indicated by MD
Provide diet as ordered Dietary/Nursing/Medical r
When necessary, prompt the resident to eat slowly Nursing/Dietary
while encouraging a swallow after each bite/spoonful
of solids or sip of liquids
Observe for signs of choking or aspiration (e.g., Nursing
choking, struggling, coughing, wet vocal quality,
watery eyes, excessive throat clearing, rales, ronchi,
fever)
Provide emergency choking procedures, if indicated All

SAFETY: AT RISK FOR ELOPEMENT

Intervention Responsible Discipline


Assess resident using the ‘At Risk for Elopement Social Work/Nursing
Decision Tool’
Inform resident and/or family of resident’s restriction Social Work, Nursing
and need for restriction
Obtain ‘unsafe wandering’ history patterns from family Social Work
Provide resident with home free watch Security, Nursing
Place resident’s photo at security desk in ‘A’ and ‘B’ buildings Social Work
Forward to staff current list of restricted residents and Social Work
hand deliver copies to security desk in ‘A’ and ‘B’ buildings
Observe that resident is wearing home free watch & Nursing
record on MAR
Record on Behavior Management Log on Nursing Assistant/Nursing
each shift resident’s observed behavior and
activity taken, as needed.
Redirect resident as needed to safe area and/or All
to activity of choice
Differentiate safety strategies for the cognitively intact vs. All
cognitively impaired individuals
Accompany resident to off unit functions/appointments RT, Nursing

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SAFETY: OXYGEN USE

Intervention Responsible Discipline


Assess resident’s respiratory status by observing All
skin color, ease of respiration, respiratory rate,
and verbalized comfort
Instruct resident on need for and safer use of oxygen Nursing
and conservation of energy strategies.
Provide secure container for cylinders and utilize Nursing
liquid units in the upright position
Provide nonpetrolium-based lip balms and lotions Nursing
Review safety of grooming items such as curling iron Nursing
and electric razor
Monitor oxygen liter flow at the beginning and mid-way Nursing
through each shift
SAFETY: RISK FOR FALLS

Intervention Responsible Discipline


Observe residents for safety and anticipate needs when All
doing unit rounds and providing care/treatment/activity
in resident’s environment
Ambulate resident per plan of care Nursing/PT/OT
Provide call bell and frequently used articles within All
resident’s reach
Answer call lights promptly Nursing
Observe for decline in strength, mobility and transfer Nursing/PT/OT
ability
Maintain bed in lowest position Nursing
PT/OT evaluation as indicated Nursing/PT/OT
Remove clutter and other tripping hazards from All
resident's environment
Modify environment as needed All
Orient frequently All
Task segmentation as needed All
Observe for changes in behavior and provide supervision All
as needed
Monitoring of resident due to unsafe condition is time-limited All

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SKIN INTEGRITY: ACTUAL SKIN BREAKDOWN

Intervention Responsible Discipline


Provide wound care as ordered Nursing/Medical
Observe for effectiveness of treatment Nursing/Medical
Evaluate nutritional needs Nursing/ Medical/Dietary
Encourage resident to consume meals, fluids and any Nursing/Dietary
supplements ordered
Record and evaluate percentage of meal consumption daily.
Weekly wound rounds to evaluate adequacy of plan, Nursing/ Medical/Dietary
evaluate healing, and record size and character of wounds.
Provide routine daily skin care. Nursing
Turn position every 2 hours and more often if appropriate. Nursing
Evaluate effectiveness of transport. Nursing
Evaluate for need to progress to pressure relief surfaces Nursing/Medical
on bed/chair.

SKIN INTEGRITY: AT RISK FOR SKIN BREAKDOWN

Intervention Responsible Discipline


Use risk assessment tool to monitor risk factors Nursing
Keep skin clean and dry Nursing
Turn and position every 2 hours or as appropriate Nursing
Incontinent care after each episode, including moisture Nursing
barrier protocol
Daily skin checks and report redness or skin breakdown Nursing/ Nursing Assistant
to nurse and medical provider (complete skin alert)
Observe nutritional intake Dietary/Nursing/Medical
Provide pressure reduction mattress on bed Nursing

SLEEP

Intervention Responsible Discipline


Provide environment conducive to sleep and relaxation Nursing
Avoid providing caffeinated beverages during late day hours Nursing/Dietary/RT
Engage resident in activities during the day to prevent extended RT
daytime sleeping

SPIRITUALITY CARE PLAN

Intervention Responsible Discipline


Identify resident’s religious and spiritual needs/preferences Chaplain
Provide information concerning religious services, program Chaplain, RT
Accompany resident to chapel RT, Volunteers
Offer spiritual counseling Chaplain/Social Work
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SPIRITUALITY CARE PLAN—Continued

Offer support for resident’s loss, illness, and change All


in life status
Offer support to resident in developing coping skills Chaplain, SW
Offer guidance regarding end of life decisions Chaplain/Social Work/
Nursing/Medical
Offer counseling for family Social Work
Encourage family/friend to accompany resident to All
religious services in community or at MSH

TUBE FEEDING

Intervention Responsible Discipline


Monitor for correct placement of tube Nursing/Medical
Provide tube feeding and flushes as ordered Dietary/Nursing/ Medical
Elevate head of bed 30 to 45 degrees while resident Nursing
receives tube feeding
Observe for signs/symptoms of intolerance Dietary/Nursing/ Medical
(e.g., nausea, vomiting, constipation, diarrhea)
Check for residuals and contact medical provider if Nursing/Medical
greater than 150cc
Observe for s/s aspiration Nursing/ Medical/OT
Review weights as ordered and assess adequacy of Dietary/Nursing
tube feeding and tolerance
Speech therapy referral prn Nursing/ Medical
Observe for early signs of malnutrition or dehydration Dietary/Nursing/Medical
Monitor labs as ordered Dietary/Nursing/ Medical
Change feeding tubing and bag every day Nursing
Observe for changes in skin integrity Nursing/Medical
Provide routine care to stoma site daily Nursing

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