Now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services and pain management. Prior to joining COPIC, she served as the Director of Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a bachelor of science from Regis University, a doctor of jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. We thank you for being here with us this morning. Laura, we invite you to go ahead and get us started. Thank you, Lindsay, and welcome, everyone. This session happens to be on something very near and dear to my heart, and that happens to be nursing. Having worked in the nursing arena for so many years, it's nice that they dedicated quite a bit of the manual to nursing, which, of course, when you're in a hospital, that makes sense because the nurse provides so much care and so much of the services that a hospital is responsible for. So that's why it's so nice to be able to present this presentation. I always include in my programs my disclaimer that the information I'm providing today is that. It's informational only. I don't intend it to be serving legal advice nor establishing an attorney-client relationship. So please consult with your own representative, your own in-house counsel, whoever that happens to be, for issues related to your particular facility. I always start with just why are we here today? Why does Georgia Hospital Association provide this? So that you don't get one of these. And that's that statement of deficiencies where you have to do that plan of correction. And no facility, no provider wants to be notified that there has been a termination of the agreement with Medicare and Medicaid. Now, this is undergoing quite a bit right now in the arena. And so we're not too sure where it's going to end up, what's going to happen. But for today's session, we don't want to get one of these. If you haven't had an opportunity to listen to any of these programs, this is how it works. Well, the regulations, what we're covering today, they all start in what's called the Federal Register. That's where the rules and regulations begin. And then CMS, which happens to be a division of Health and Human Services, they have the responsibility to put out that regulation in a transmittal to their surveyors. They have to develop interpretive guidelines and survey procedures. It's like, okay, this is what it means and what we're going to be doing once we're on site. And of course, they're to update the manual. Three types of surveys, certification, when you're getting started, a validation. If they're coming back after a previous survey, or if perhaps you happen to have one of the deemed status, they've been going along and doing validation surveys. And then, of course, the complaint survey, which that's when they really do quite a deep dive in what's going on and what's related to that particular issue. What we're covering today in the acute manual is what's called nursing services. They are very separated out, but for critical access hospitals, they combine them under what's called provision of services chapter. And so they are interweaved in between those. Now, I mentioned no one wants to get that notice of deficiencies. I have to do a plan of correction. Some of the more common deficiencies that came up with nursing and the tag numbers we're covering, and we're going to cover these issues as we go through here. But one, they didn't make sure there was an RN who was supervising nursing care, because in that particular situation, physician orders weren't being followed. If that had been where they had an RN supervising it, that would have been caught. They didn't follow their own policy and procedures on administration of insulin. Insulin is a high alert medication. They didn't make sure patients who happen to be in restraint seclusion were monitored not only according to the orders of that provider, but again, their own policy and procedures. They didn't follow up on allegations of abuse. We are required to do that. They didn't make sure that they provided adequate care regarding a retention catheter or securing medication carts, not adequate or proper supervision of some of the ancillary staff, such as a medical assistant. They didn't make sure the RN supervised and evaluated care for each patient. And in that situation, there was no bed alarm in place or activated who for a patient was at risk for falls. And then just finally, a few more. They didn't make sure the interdisciplinary care plan was developed in response to the patient's needs. Those who are at high risk for falls had a care plan or precautions that were developed and put into place. The RN, they did not make sure that they were supervising implementation of the patient care plan. And sure, this went way down to basic nursing care, like waits, INOs happened to be recorded. And then no nursing care plan updated when there were new problems that happened to be identified. So as far as any particular memos, I want to talk about these memos because these memos come out from CMS. And again, they are directed to changes that are going on in the regulation. And they really impact nursing. A lot of these do. So I want to talk about those that really impact nursing. And Lindsey did mention we have a few questions. So just a really quick one. Lindsey, if you'll put that up for me. Absolutely. So you should all see this on their screen that says, we have had challenges staffing for patients who may be suicidal or at risk for self-harm. One of the challenges has been finding ligature safe rooms. And your options here, yes, no, or not sure. We'll give you a couple of seconds to put in those responses there. And if you missed our very opening comments here, if you have questions for Laura throughout the presentation, there'll be several of these opportunities that polling questions are going to come up on the screen. And you can use that opportunity to type in your questions in that Q&A option that you should see at the bottom of your Zoom window. Or if you don't see that, you can, of course, type your questions into the chat. We'll make sure that we address those questions throughout the presentation as well. OK, we are getting some mixed responses here. I'll go ahead and end this and share those results. And again, some of these are just simply informational only for me. So it looks like some of you are having these issues. And I bring this up because there was a memo that came out in July of 23. And it talked about ligature risk and doing that assessment because we, of course, want that safe environment so patients don't hang themselves or hurt themselves. And this really did focus on those behavioral health units, the patients and the staff. By the way, if there are any ligature deficiencies that a surveyor might find, there are no waivers. You will be cited and you must do monthly progress reports if there is a ligature risk deficiency. So for this memo, there were three main areas that they were focused on. Patient assessment, your staffing and monitoring of the patient. How many staff do you have? Can you monitor it? And then your environment. What's that environment look at? For patient, you should be able to show how do you identify those patients who are going to be at risk for either harming themselves or others? And then, of course, take steps to reduce those risks, minimize them using national standards, national guidelines. And they did really spell out in that memo, what are those potential risks? Whether it's actual ligature or maybe it's access to lighting fixtures where they can take the cords and then harm themselves. Even something as simple as a plastic bag in the trash can. They did talk about having a screening tool that's really appropriate to your population and your care setting. But then don't forget your staff competencies because they have to be the ones to do this assessment. We need to screen our patients, of course, anyone in a psychiatric hospital or unit. For those of you in acute care, if you do have a patient who has, maybe they're on your floor and they have a behavioral health issue, that's the reason for admission. You really need to be screening them too. And then anybody else according to your hospital policy. Perhaps you have a pediatric patient who's done some self-harm through cutting. Now, would that be, maybe they're going to expand their risk to a ligature risk. On staffing, of course, we have to have enough level of those appropriately educated staff. Those who are trained to recognize these folks who are at risk. Those who can look at the environment and say, no, we need to get this out of here. And that includes everybody. Doesn't matter if it's one of your employed staff or it's someone you have per diem or contract, whoever it happens to be. You are expected to provide training and that's assessment of these folks' abilities. On initial training, on initial hire, anytime you're updating or changing your policy and procedure. Otherwise, every two years after the initial. On your environment, take a look around at what you have and what is the floor? What's the unit? Because that's going to differ according to what you have. If you have an ED safe room, that's going to be very different than if you have, say, a multi-area, like you've got several carts in the area. That might be very different. Also, your patient population, as I already mentioned, if you have a patient who has some of those behavioral health risks, very different, maybe more of an assessment than a person who's coming in because they tripped and maybe cracked their knee on a stair or something. It has to be appropriate to that unit. Now, this can be a little challenging when you're on a med search unit and you're getting patients out of ICU who have tried self-harm. Then you really have to look at the room where you're going to place them. You may have those patients who are at risk for self-harm. I already mentioned no waivers or any deficiencies. That's our ligature risk. Nurses take care of patients. Another area nurses are heavily involved is discharge and discharge planning. Memo came out June 23. Obviously, 2023 was a busy year for them. Here they reiterated that you have to have an effective discharge process that really looks at what does the patient want in their goals and their treatment preferences. Of course, we include the patient and their caregiver and their partner, whoever that happens to be, in that planning. We know we have to discharge or transfer them to where it's applicable. We send along all necessary medical information that took place, what happened when they were in your hospital, what care did they receive, and what do they need after the fact? This information has to go to that appropriate post-acute care provider, whether it's an agency, home health, maybe it's your durable medical equipment provider. Maybe you've got a baby who needs those billy lights. That's part of your discharge planning. Who's going to provide it and who's going to train the mom and dad on it? Because they found a lot of this had missing information. When that happened, we had an increased readmissions. That was the goal behind here, that with appropriate treatment and discharge planning and care, we can decrease those readmissions and, of course, decrease any adverse events. They found that when we didn't have that information, the equipment wasn't there, they had to come back in. Now, you have the discretion on developing your own policy and procedures on meeting them, but there are six areas you must address in those policy and procedures. Of course, medications. Do your medication reconciliation. Durable medical equipment. Is it there? Is it available? Do we train them? Have we trained this individual or the parent on how to use it? What's the skin condition? You're transferring them to an extended care facility. How's their skin looking? Are there any tears or initial breakdowns? Have we communicated with these providers after hospitalization? If you have those patients who happen to have behavioral health needs, substance use, have we communicated that to that next level of care? And then finally, put in there that we always are taking into account what's the patient's preference and goals for care. Another area I want to talk about is nondiscrimination. Now, this is an entirely separate program, but I wanted to hit on a couple areas specific and how they really impact nursing. Overall, it's under the Office of Civil Rights, Section 1557. There were a lot of changes that came out during the 2020 timeframe, and it included OCR 1557 of the Affordable Care Act, by the way. Now, CMS at that time had said, hey, we'll add all these sections to our conditions of participation, and we'll put it in our Improvement Act that came out at that time, but that meant there'd be two different laws, so they decided not to put them in the final conditions. But if something comes up, let's say it happens to be an issue on a translator, and CMS is in there, they're doing a survey, they find out you're not meeting that requirement for effective communication, they could send that issue over to the Office of Civil Rights, and then the Office of Civil Rights could come in and do an evaluation. Overall, you have to have certain required signs. One, how are you going to handle complaints or grievances from patients or their representatives, nondiscrimination in actually providing care, interpretive services at no charge, and EMTALA. I'm not covering EMTALA here, that's a separate program, but these are some of the required signs that we have to have available. How are you going to post them? Where are you going to post them? Like in the emergency department, OB, admitting, that's a common place where you'll see it in admitting. For grievances, you have to have someone to handle those complaints, and that has to be in their job description. And you have to have a policy, and staff need to know about that policy. They don't have to know word for word, but they have to know about the policy, and that they're competent. So if a patient complains, what do they do? Who do they go to? What's the process? On nondiscrimination, I mentioned it's part of the Affordable Care Act, and that prohibits discrimination based upon those protected classes, race, color, sex, age, disability, in these health care programs. And it builds on that longstanding nondiscrimination back from the 1964 Civil Rights Act. Some other changes that happened. Now, some of this information on this particular site, that's pre-DOBS. So what you want to do is make sure you're checking with your state on any particular specific restriction or additional information. So here in this one, the judge came back and said, hey, you can't force a hospital or provider to do something that's against their religious beliefs, whether it's an abortion or gender change. So OCR went back and said they will change their definition of sex so it doesn't refer to gender identity. They rewrote that according to the ruling. In 2021, HHS said, no, you know what, we're going to go ahead and reinforce that based upon not only sexual orientation, but gender identity. In 22, federal court in Texas came back and said, no, that's not right. You overstepped the definition. So OCR went back. Now, we know that's been undergoing massive changes. So in 2022, they enhanced some other laws in that. And by the way, as of just recently, gender identity is coming out of everything within Office of Civil Rights in all of their publications. It will be coming out. They are now going and reverting to the plain definition of male and female when it talks about sex. So gender identity is not going to be included in those. Some of those publications are not out yet, but that's the way they are going to go. It will now be male, female. On language assistance, we've known this for a long, long time. We have to provide interpreters. These folks have to be, they have to be qualified, not certified, but qualified. We have to make sure there's auxiliaries if that works. Some of you may have those small little machines where you can turn it on and it's either sign language that is provided or it's typed out. It's a verbal translation. So those who are hearing impaired can have access to that. You have to post a sign so that they know this. CMS has a sample notification and make sure your staff know. Now, this happens to do with interpretation. Post a sign, 15 languages, tag languages, simply says translation services are available at no charge. OCR has that list. Four states and the District of Columbia have 17. So if you see your list, your state listed, so it's Colorado, Maryland, Rhode Island, and Virginia, you have 17 languages. And again, likewise, with any grievance, you have to have someone who handles these grievances. There is that document. I have it here listed. When you go to that link, go to where it says Appendix A, that will give you that list. If you have one of your own, the sources they're based on that you can rely on them, another reliable source, great. You can use it. Otherwise, I'd make your life easy, use the one OCR has because that's what they're going to look at is that included. And here's just an example of what those look like. Here are those by state. It will list how many you have. And for those of you who have 17, they have combined 15 through 17 to list. These are the ones you have to have that translation service available. So those are some of the big memos I wanted to hit on that really impact nursing. By the way, on that gender identity, we don't have anything yet. There is no memos yet. Since it does involve a lot with OCR, it may take a while to get that out, but that will be provided as soon as possible. Alright, let's go to the conditions of participation. We know that if you participate in Medicare or Medicaid, you have to meet it for every patient, everybody. It doesn't matter if it's Medicare or if it's a Cigna, Blue Cross, doesn't matter. If you have the deemed status, that means that you can get paid for Medicare and you don't have to go through a state agency survey, but they may show up. And sometimes they may be a little more restrictive. So just be aware that, yes, joint commission is there, you have deemed status, but sure enough, the state shows up. Don't be surprised. So we start on TAG, and this is in the acute manual. It will start with TAG A and then a zero, it has to be a four-digit number, 385. That's where we're going to be starting. You have to have an organized service to provide 24-hour care, and that means you have at least one RN who either furnishes or supervises that care. Short, you have to have an RN on duty at all times. They are integrated into your hospital quality assurance performance improvement program. The surveyor is going to talk to your chief nursing officer or DNO, whoever that person is identified. They want a copy also of the organizational chart, because what they're looking for is the chain of command. They want to see the job description, and not only for just nursing, but also the chief nursing officer. They will then take one patient from every inpatient unit. They're going to watch the care being provided. They want to make sure you have enough staffing, so if that patient puts the light on, that's someone's there to respond. And they're going to look at the medical records. They want to look at the care plans. Has it been done? Is it current? Has it been updated? Now, on adequate nursing, some of you may have heard about the event that happened in, I believe it was a northeast hospital where a patient died in the hospital bathroom. He had turned on the emergency light, and no one responded for up to 15 minutes because of staffing issues. Yes, there will probably be a citation based upon that, but again, that was a staffing issue. They want to make sure there are enough folks hanging around. Your director has to make sure that they have the authority and that there's delineation of responsibilities for patient care. So this CNO, and I'm just going to use CNO for ease of understanding, they have to be currently licensed RN, because they're responsible for the operation of this department. They have to determine the number and types of nursing personnel and staff. That's not just nurses. That can be orderlies. That can be if they want an assistant director. How many unit clerks do they need for that particular area? Maybe using orderlies, EMTs, whatever it happens to be that's accepted within your hospital. The service has to be hospital-wide. One nursing service hospital-wide. And that includes, the operation includes the quality of care that is being provided. So what is the surveyor going to do? Well, first off, they're going to make sure that, yes, you have a CNO, but that this individual approves any patient care policy and procedures. They develop the staffing policy and procedures. The surveyor will look at your chart again. They want to see the lines of authority, and they want to read the job descriptions. Does it spell out the duties and responsibility? Not only of the chief nursing officer, but the nursing services. On talking about staffing and delivery of care, of course, we know we have to have enough take care of the patients. Now, you may have one RN. If your unit's small enough, you may just have the one RN or two RNs, and the rest are ancillary staff, whether it's LPN, nurse's aide, however you want to term them. But there has to be qualified supervision personnel. In short, you have to make sure there is an RN who is immediately available to step in and take care of a patient if they need be, whether that's the charge nurse, the unit charge, whoever it happens to be. Every department or unit has to have an RN present. If they're on two units at the same time, that's not going to be compliant, because that person has to be bedside of any patient. That means you may have to revise your staffing based upon your absenteeism. Now, talking about immediately available. Well, again, if they're working on more than one, that's not meeting the requirement. Now, it doesn't matter, by the way, if this is inpatient or outpatient. It's the same requirements. So let's say you're in outpatient surgery and this person is getting one of those initial doses of antibiotic, okay? If they call and say, you know, I'm not feeling funny or I'm starting to itch or my mouth is starting to feel funny, an RN has to be able to step away and go take care of that patient. If that nurse can't get there, you have to have a nurse then available to go see that patient. So that's what you need to look at for your staffing. The surveyor is going to look at your schedules. What's your acuity? How many patients do you have? Look at the training and experience of that personnel. You may have a phenomenal LPN who can help with some of this, but nonetheless, you still have to have an RN there. What's the layout of your hospital? I worked in a hospital where we had some very long hallways and they smartly put the nurse's station smack in the middle so that we could keep an eye on each and every room, no matter how far down the hallway they were. And we had two separate staffing areas for each side of that hallway. By the way, they're going to look at medical records. They want to make sure care is provided as ordered. So they'll look at the orders and then they'll look in the notes to see what's that documented. By the way, we do know there are studies out there on staffing numbers, excuse me, and outcomes. The better and higher the staffing numbers, the better the outcome. This was the first time that ever came out. This was from, you know, it was back in 2007, but this study hasn't changed. AHRQ put out a study on staffing and nursing care. And I think there was one little comment in there that said, by the way, if you want better outcomes, go to the hospital that has a lower nurse patient ratio. You'll have a better outcome. Institute of Medicine, they also link staffing to safety. They even put out their recommendations, limit how many hours you're working that nurse so we don't have fatigue. They suggest no mandatory overtime and never over 12 hours or 60 in one week. They do notice a three times increase in the error rate. That's pretty significant. Fatigue does hit your nurses. It does. Just like your physicians, it hits the nurses. Other areas they found not only increased error medication rate, pressure ulcers numbers they found went up because staff weren't able to get in there and turn the patient, reposition them. UTIs went up, falls went up because we couldn't be there to help that patient get up and down. Links of stay were increased, readmission rates. Again, this was back from 2004, but these numbers haven't changed. There is actually a three volume handbook on nursing and it talks about staffing and quality of care. And I have that link down there for you. It's from the American, excuse me, Agency for Healthcare Research and Quality. And now up to question number two, Lindsey. Okay, let's get that one up here on your screen. Okay, so you shall see this one that says that Hospital B is a 320 bed hospital with service provided on three floors, an average daily census of 275. It experienced a major nursing turnover in the past year with a significant shortage of registered nurses. Hospital B runs with six RNs per day. Will this be a possible issue with CMS? Yes, no, or not sure. Are your options here? I'll give you a couple of seconds to put in your responses. And again, this is a good size hospital. So yes, they have an ICU. They have an intensive care unit. So it is a joint surgical and coronary care intensive care unit. It's a large unit, needless to say. Okay, we're still getting a couple of responses. I'll give you just a couple of seconds here. See some of you still putting those in. Okay, great. Here are those results. Yeah, yeah, they probably will be cited. Yep, because just the vast numbers. When you're running at almost capacity everything all day, I think they're at risk. And they understood, yes, indeed, we know you're running short, but you've got to account of a date for it somehow. And again, each unit has to have the RN. And if there are more than one unit, no, it's not gonna work. They'll probably be cited. So moving on, again, RN 24 hours a day. And the exception though, if you're a rural hospital or you have a waiver for a temporary shortage of nurses, here what you have to do is you have to make sure, they actually put this in, you have to make sure salary offered is comparable to your three nearest hospitals. This is for your waiver that you're getting it into place. The requirements are you have 50 or fewer beds. It is only a temporary waiver of that 24 hour RN on site. And the regional office gives that. The surveyor will be there because otherwise they wanna make sure there is an RN on each unit 24 seven. Excuse me. Another thing we have to do is make sure our nurses have a valid and current license. Because by the way, there's an easy way to do that. And I'll get to that in a minute, but we have to make sure it's current. This slips our memory. You know, some of us forget unless our nursing board is really proactive and sends out notices, it's time to update or renew your nursing license. My state used to do that. They're not so good anymore. So you have to have some way to trigger them to remind the nurses, by the way, your nursing license is gonna lapse here. And of course, make sure they meet all the standards if you require continuing it, or if your state requires continuing it. They will look at license verification policy and procedure and then HR records. Are the staff working that day currently licensed? And this is one way you can do it. Again, the state boards are nursing. They will have an online verification process. It is considered primary source verification. If the nurse can't seem to get around to it, you can do that. You can print it out and keep it in their folder. For your advanced practice nurses, don't forget the Office of Inspector General. They have what's called the list of excluded individuals. This is when those folks are now no longer eligible to participate under OIG and Medicare and Medicaid. They have that list that they keep. I kind of equate this to the National Practitioner Databank where you can go in and find out. This is where you can actually go in and find out who is not eligible to participate. Next tag number talks about NARIN for every patient because that person needs to supervise and evaluate the care that's being provided. So that means they do the admission assessment. They're making sure standards of care are being met and the policy and procedures are being met. This is a very problematic standard. This is where I found most of the deficiencies was under tag A0395. The evaluation, what do the patient need? This is the assessment that they are in needs to do. What's their health status? First off, when they get there and then as their care progresses. And how are they responding to that intervention? Is that painkiller really working for them or is it making them so nauseated that they can't take any fluids in? And then you gotta go start the IVs or whatever you need to do. It prolongs their stay. How are they responding? One thing that does need to be present is a nursing care plan. For each and every patient. And this doesn't matter if you're part of interdisciplinary care group, you still have to have a nursing care plan. Because the plan reflects what the patient goals are. And how are we going to meet those needs? They will ask during the survey, we need to see the following patient's care plans and they'll go through them. Because what they wanna make sure is that there's an assessment to meet those treatment goals. So for example, and I've got this on the next slide, multiple trauma patients having fractures, they were up and moving around of course before, now what are they gonna do? This is gonna be a long recovery. Maybe this person wants to go to an extended care facility with a great PT service or maybe somewhere close to where they live. Maybe they have to go away from their home because of limited resource. Then maybe after they're done there, they're gonna go live with a family member and they can take care of them. All of that needs to be part of the care plan. Where is this patient going from the minute they hit your door until they're out of there? They say in the interpretive guidelines that the care plan starts and admission includes any psychological, physiological or discharge planning factors that you need to take into account. Because that's what your goal, your assessment must include. How is this patient responding to this illness? Keep it up to date based upon their ongoing assessments. Miss, we're doing a care plan on a patient. She was in the critical care unit then she was on her step down and just sitting there kind of tidying up her room and she said, yeah, I'm a little worried about going home because my husband won't take care of me, he won't do anything. So I don't know what I'm gonna do when I go home. So we need to go back and look at her discharge planning because the plan was she was gonna go home and her husband was gonna help take care of her and we knew that wasn't going to happen. So we needed to go back and start considering home health for this individual. I mentioned the interdisciplinary plan of care still have to have a nursing plan of care. It can be part of it, can be part of that major one that's great because then something specific to your services can be perhaps communicated to that entire plan. It's always part of the record and it started soon after admission. They will look at anywhere from six to 12 care plans. If you are a very busy unit with a high turnover, they may wanna see a few more, don't be too surprised on that. Next tag number, the RN assigns care to each patient according to what that patient needs and the qualifications of the staff. Do as I mentioned, did you have a very excellent LPN who can take care, maybe the heavier load patient that doesn't need too much assessment or maybe a little bit of assessment or do you have that patient who really has to have a lot of assessment and nursing interventions? The CNO, they have to make sure all staff have the right education, the right experience, they're competent and they can take care of that patient and each patient they're responsible for. That may be that each nurse will have a CLS training, that each nurse will continue with their continuing ed care and units and education based upon that specialty like pediatrics but that's where the CNO makes that determination. Surveyor looks at assignments, make sure they're qualified, they'll talk to the charge nurse on duty that day. What do you take into account when you're making assignments? Do you have a high acuity patient? Maybe you have someone who's really competent in that area so perhaps you decrease their staff or their patient load and then what other qualifications you have out there that maybe can step in and help if need be. Now this doesn't just affect your own employee, it affects agency nurses also. They have to follow your policy and procedures so the chief nursing officer has to make sure there's enough supervision and evaluation of those agency nurses. If they're there more than once, it's at least yearly that yes, you know indeed. Usually the hospitals will try and staff with the agency nurses, those who they know and those that they're comfortable with so they're very familiar with their qualifications. What if you're gonna use volunteers on your floor? Chief nursing officer is responsible to make sure that they're helping out in any way that involves nursing care that they're still competent and that they are supervised by an RN who is an employee of that hospital and then make sure they're included in orientation. Some kind of orientation, whether it's to the unit, the emergency procedures, policy and procedures, at least know where to get them or who can they ask if need be. I mentioned that outpatient, you have to have a list of those outpatient departments that have to have an RN present. That's based upon what you're doing, level of acuity and then basic standards of practice. So in other words, if you have an interventional radiology department, do you want to have an RN there to help take care of that patient? Monitor the patient or if you are doing a patient who's on a ventilator, who's gonna take care of that ventilator? Ventilation portion of it while that patient is say down in CT. CNO, they approve all of these staffing plans and how they're going to occur and they look at this every three years. Now, this is one tag number where the interpretive guidelines and survey procedures have not been developed by CMS yet. It is still pending. So I already mentioned, these are just some examples and I always like that large radiology department, maybe they help with these procedures, especially if they do require sedation. So let's move over from nursing and let's go now more into medication. And I mean, as far as nursing staffing and what you have to have. Medication administration, it's what we do. It's what nursing does. And of course, we know they have to be prepared and administered according to any laws where it's federal or state laws. The basic is we have to have an order, a practitioner orders and that has to be in the medical record. Meds have to be administered either by or under the supervision of nursing or other personnel. The medical staff, they determine who can administer those medications. That could be a PA. So that's what the policy and procedures for medical staff have to determine. Now, of course, all of these have to be allowed by state law. Do you allow your RNs to give certain meds or not? Do you allow LPNs to give IV meds? The first place to start is the state. Do they allow LPNs to administer IV medications? And then hospital policy and procedures, bylaws, rules and regulations. So there's a lot that goes into who can administer a medication. Errors, the interpretive guidelines talk about studies on medication errors in our hospitals. We're very familiar with the Institute of Medicine and they found drug-related adverse outcomes were about almost 2 million in patient stays. 830 some thousand patients were treated because of adverse events related to medication. This is despite everything we've done to try and prevent it, whether it's barcoding or CPOE. We know meds have to be prepared, administered according to standards of practice and federal and state laws. There are specific organizations, CMS lists out in the interpretive guidelines. I'm not going through all of these, but those of you listening, that's on slide 69. So these are just some of the specific organizations. They rely on these folks to really make the standards of care. As far as orders, standing orders, outpatient orders, this includes those practitioners who may not have privileges, but by the hospital medical staff policy and procedures, they can order medicines. So let's say you have a physician, practices in your community, doesn't have privileges, but the patient's coming in for a procedure or having something done, maybe labs drawn. They have to have an order for those labs. Are you going to allow them to do that? There are two exceptions to that, Clu and Pneumovex. Here you can have the protocols where the nurse assesses the patient for any contraindications prior to administration, but the orders have certain requirements. What's the name of the patient? If they use certain weight and age for calculation of dose, yes, that has to be included. Have those policies when you have the children or the infants on which measurement type you'll use, like kilograms, or maybe you're going to use grams. Anything that also affects an elderly patient, maybe you have a very cascadic patient that we have to keep an eye on their renal status or even their liver function. And you have to specify in a unified approach how these orders are going to occur. So if you have a pediatrician, they're ordering it the same way as a physician on a med-surg unit, in other words, following your policy and procedure. Another mandatory component is date and time of the order. Several years ago, they noted some of these things weren't being dated and timed, and they couldn't determine, okay, when was this thing to be administered or not? So they did add that. Other requirements, of course, the name, dose, and frequency and route. Then when it's applicable, strength or concentration, quantity and duration, think your antibiotics, any specific instructions for use, and of course the name of the prescriber. Who is making that order? Who's writing that order? The medical staff, or if you have a medical executive committee, they have to approve any policy and procedures on administration. As with anything, it has to be a part of your QAPI process. And consult with your nurses and pharmacists on some of these policies. They can really help you with it, especially when you get late admissions or patients coming back late from, let's say they're coming back late from recovery and they're on a time dose. That's why it helps to have nursing and pharmacy involved in what's the best way to get a therapeutic level for that particular medication. There are many specifics CMS has to be included in this policy and procedure. And of course, consistent with state law and scope of practice on medication administration. So the policies have to identify who can prepare and administer medications. I have the page number there. This is on appendix A on where you will find those categories and qualifications. What medications can they prepare and administer? I just mentioned I'm in Colorado. Our board of nursing now says LPNs with additional training can give certain IV meds. 10 years ago, even five years ago, that was never heard of. They didn't do it. And we have now realized they can do this. What are the education training requirements? CMS does have some of those recommendations. Of course, anything during orientation and for your continuing ed. Here's some of the things they may include. Handling, preparation. Why are we given this medication? What are the side effects? Interactions, compatibility. What equipment do you have to have? Any special procedures or techniques like setting up the IV pump, the PCA pump, the tubing. What kind of tubings do you have to have? Include and address components of training in your policy and procedures. What do you want during training in your initial orientation? And then to show I'm still competent. And don't forget to document that training. Include it in their personnel folder. Most of us are familiar with the five rights. The basic, this is just the minimum standards of five rights. That's what your policies have to reflect in the standards of practice. Right patient. In other words, what identifiers are you going to use? Full name, date of birth, patient ID card, whatever it is, maybe the patient's statement. What's in your policy to say, who is this person? Right medication. Does it match with what's prescribed? And we do not have an allergy. That's always a big one. Right dose. By the way, we're still continuing here. Right dose. Right route. In other words, it can be oral or parental. And right time. So we have that frequency and time of administration. Then there's the process. There are five stages of that process from ordering to monitoring. In other words, we get the order, we send it down to pharmacy and it's verified. Pharmacy sends it up, dispenses it. Nurses administer it. And then we watch the patient. How did they respond? Was there anything we need to look for? They do talk in the interpretive guidelines about recent literature. They even talk nine rights now on administration where they've included documentation, action form and response. How many you use is up to you. But definitely the basic five must be a part of that. They even talk in the guidelines. That's right after this nine levels here. Culture of safety. That staff have to feel safe in speaking up. In other words, if they've got a concern about that order, it's like, hmm, do I feel safe talking to this provider or am I gonna get yelled at? And those of you who've had that experience, you know exactly what that feels like. Can they question that order? Now granted, a lot of it has to do with how they approach the provider and ask them. But again, they have to feel safe in speaking up and that they get a prompt response. They do talk about injection practices that they're following standards of practice to prevent any healthcare associated infections. By the way, not only are assessed here, but you're assessed under infection prevention and control. Compounded sterile preps, we know they can cause healthcare associated infections if there is a slip up because your nurses may do this for immediate use. In other words, they're diluting that medication and then they're administering it or they're adding it to an IV bag. Institute of Safe Medication Practices, they have guidelines. They put it into factors that increase the risk in adults and it talks mainly IV injectable medications. And about 90% of your hospitalized patients are gonna have it. So I've got what that looks like here. That has not changed. So the guidelines haven't ready to administer form. So there's no guesswork. Use those commercially available refilled syringes, especially for flushing. If it's available in a single dose, buy it. Use that aseptic technique, meaning washing your hands before and after, cleaning off the diaphragm, even if you just pop the cap off. Dilute medications only when it's recommended by the manufacturer using those guidelines and your policy and procedures. If it does require dilution, then in a clean, uncluttered, separate location. Don't take meds from one syringe and put it into another for administration. And meds shouldn't be drawn up using that resaline flush. That's not for dilution, that is for flushing. Putting more than one med into a syringe is seldom necessary. Yes, we used to do it, that was standard. When you had to give, say, Demerol Invisible Pre-Op, because we thought, oh, we'll say Mopoq, not mentioning or recognizing, hey, that could cause some changes in that medication. Of course, we don't use our mini bags as a common source to flush. We label our syringes, unless there's no break in holding onto that syringe. This came under fire because it used to be that everything, every syringe had to be labeled, no matter what. But with the American Society of Anesthesiologists, they said, you're going to waste valuable time in doing that. When I got a hold of that syringe and I'm the only one who has it, I know what's in it. And so they did go back and update it so that if the syringe never leaves that person's hand, it's okay, you can just draw it up and immediately administer it. Just make sure you're administering at the rate the manufacturer does suggest or evidence says, because sometimes we give it too fast. There are recommendations and guidelines from the CDC on preventing transmission, and it really puts our 10 recommendations into that. Follow those, because again, we are expected to follow nationally recognized guidelines. That's the link available. I have it also in the appendix for you. So here's our third question. Lindsay, would you put that on for me? I sure will. Okay, so you should now see this on your screen here that says, hospital D has floor stock of vaccines and saline sterile water for dilution as needed. All vials are multi-dose and expiration date clearly printed. During a state survey, several vials were noted to not have a beyond use date printed or affixed to the label. Nursing reported this was a duty of pharmacy, but pharmacy said that it was nursing's responsibility. Will hospital D be cited? Yes, no, or do not know here. I don't see any pending questions at this time. I know we're getting close to halfway through or so, Laura. So if anybody has any questions for Laura or for her knowledge, the material that she's presented so far, please go ahead and type those into that Q&A option there at the bottom of your Zoom window. Or if you don't see that, you can, of course, just type your questions into the chat as well. Great. Okay, we've gotten a pretty consistent answer here. We'll go ahead and share that result. Yeah, I had to go. Yeah, hopefully nobody's ever run into this one because it was somewhat of a lack of communication, I guess is the best way to put it. So what happened in there is they actually had to have pharmacy and nursing sit down in the same room and come up with this plan that who's going to put the Beyond You state on there. And by the way, it ended up being pharmacy. The nurses felt that pharmacists would have a better understanding of the lifespan of that particular medication. And so they did change the policy and pharmacy then took on that task of putting the Beyond You state on there. But somebody has to do that because we know they outdate either after expiration or the Beyond You state. The manufacturer, they set the expiration date. And that's, of course, what they sent off to FDA and say, hey, this is the drug we want to have and how long it's going to last. But the Beyond You state, that takes into account anything that could happen from the minute it left the manufacturer until it was actually administered like changes in temperature or where did it move? Was it diluted that could grow microbials to it? This is also based on information from the manufacturer. And so that's why policies have to really be clear who's going to determine it and how they determine that Beyond You state if the manufacturer does not provide it. So again, we have the expiration date where you don't use it and the Beyond You state. The Beyond You state can never be after the expiration date. The expiration date is, that's it. You toss it after that, no exceptions. But the Beyond You state, it's going to be shorter because things haven't gone into play yet to activate what's going on with that. On administration, used to be, you had to give within 30 minutes. If you didn't, you were out of compliance and you had to write up an incident report and it was just a big old nightmare. Didn't matter how long the patient had been on the medication. Somewhere along the line, we said you had 30 minutes. Well, now we've loosened that requirement. And what they did is they worked, CMS and a couple other agencies worked together, came together and realized, you know, some of these meds, we have a little laxity in here in giving these administration time. So now we have three blocks at times. Just make sure your policy is up to date on that. So you have to address timing of medications regardless in your policy. That's of course, what kind of medication are you giving and why? Your policy has to include a couple of things. One, those medications or categories that are not included in the scheduled dosing times and then everybody else. Everybody else that's eligible for dosing times. And also in your policy, what happens? Those eligible that can occur maybe outside that timeframe or that window. And then finally your policy, how are we going to evaluate these timing? How are we adhering to these timing practices? So there's again, four steps to that policy that must be included. So the three timeframes, we have time critical, hour before and after and two hours. So I'm gonna go into depth a little bit more. First, let's start with those who aren't eligible. They're not falling under this. We're gonna begin with nine, one, four, et cetera. Here's those where the exact time is so critical. It is based on the diagnosis and what are we treating them for? What's the goal behind that? Whether it's a stat drug, a loading dose or maybe we're doing it before and after peaks and troughs. We're trying to determine their drug level. But we also have it for two other class. PRN meds are included. Those are not on a scheduled timing. That's as needed. And then investigational drugs. Investigational drugs have to go quite a bit. A lot that goes into those investigational drugs that they have to comply with. So that's why they omitted them from these that are eligible. Those that are eligible, it's where we have a repeated cycle of administration. Whether it's daily or three times a day, whatever it happens to be. Because what we're trying to get here is that therapeutic blood level. Policy include those standardized times. This way pharmacy knows when to send it up. When does the nurse have to check the patient? How's their pulse? What's their serum level? Whether it's potassium, maybe it's their INR, digital level, whatever it happens to be. Blood glucose. Hour before and after gives you two hours. Two before and after gives you four hours. So your policy has to address for these that are eligible. When is the first dose? When, if you're going to allow it, when can nurses use their own judgment regarding the next dose? What happens if we miss a dose? Whether it's late or just simply omitted. Forgot about it. Those meds or classifications you can give outside of dosing times. And those units that you're not gonna be following this dosing time, like ICU. Maybe you have a particular unit, maybe it's your dialysis unit, you're not following these dosing times. Those particular units. You may not have any, but if the case is, then you have to identify that in your policies. Time critical. A couple of them. Here, if you give it before, after, it's gonna really impact the therapeutic effect of that medication. So that's what the policy has to include. Administered within 30 minutes of that dosing time. So you have an hour total. If it's at nine, you can give it at 8.30 or you can give it at 9.30. Those meds that are always time critical. And they've just listed out some of these in their interpretive guidelines. Insulin. Maybe it's your, those you give more than every four hours. Anticoagulants. These, we really have to have that timeframe held to. Then there's the non-critical ones. Here, you've got two dosing times. These are the ones where, okay, it's a little bit longer or shorter in between the scheduled time. It's not gonna have a huge impact on that effect. Maybe it's daily or monthly. Here, you have two hours before and after. Or you have one hour before or after. So again, like Allegra, they take it daily. Or maybe Dig. They've been on Dig for several years. And they're not feeling well in the morning and you don't get it to them until noon. That's okay. If they normally take it at 10 in the morning when they wake up, but they're feeling okay at noon, all right, that's fine. Then you can give it. So that's what the policy has to stress. Also, what if they can't make that timeframe? It's even beyond that one. They're out of the department. Maybe they don't want it because again, they're not feeling well. Now you're up to four hours for that two-hour window of time. When can the staff use their own judgment to reschedule that late or missed dose? Either way, we have to notify the provider because they may decide, give it now, and then give the next one an hour later after it's scheduled time so we get them back on track. They may even say, skip the dose. It's not worth it. Just go back and start the timing again. We have to notify the attending. But we also have to do it. This is step four of that policy overall. We have to evaluate our policies on timing and how is staff adhering to that? Is it safe? Are we giving effective administration? Here's your QAPI requirements here. Errors on timing have to be tracked. We have to analyze them to determine why is this happening? Because if it's not anything in particular, then, or maybe it is, medical staff has to go back and look at those timing policies again. Do we need to reevaluate them based upon our patient population or the particular unit? How are we going to do that? Now, again, every unit has to be involved in our timing policies. They have to recognize them. We, of course, have to monitor our patients. How are they responding? Are we meeting that therapeutic effect? Are there adverse events that we have to be prepared for? And then if so, take those corrective actions. This could be tough on some of these meds. How do we know that antibiotic is working? Well, fever's gone down, okay. Sight's starting to look better. All right, patient's looking better, okay. But is it really addressing what we need to? Are we just masking it? Include any clinical data. Don't forget your toxicity. And signs and symptoms from the patient, whether it's confusion, itching, whatever it happens to be. They talk in here, risk factors, that we have to take those into consideration and those that just simply go along with the medication itself to determine how often we monitor those patients. And of course, tell everybody on your handoffs when that does occur. This patient had severe nausea when we gave him the codeine, the opioid. So we're going to have to switch it or at least make sure they have something in their stomach to help with that nausea. Always report any adverse reactions, whether it's anaphylaxis, respiratory depression, or simple nausea. They need to know how that patient's responding. They list out in the interpretive guidelines several of our patient risk factors, everything from age to asthma. Maybe it's the first time they've gotten it. Medication interactions. Are we defeating our purpose in giving these two different meds at the same time or at different times? Obesity. How's our weight doing on our patient? Our very tiny patients. Are we giving them too much? And sleep apnea. We have high alert meds that we have to keep an eye on. Regular assessment of our patient from pulse ox, maybe vital signs, sedation levels. And we report them. And please ask the patient, by the way, have you ever taken this narcotic before this medication? You let me know if you start to feel different or you feel something that doesn't quite feel normal to you like you don't normally feel well, like you feel lightheaded, or the room is spinning, or you're having trouble controlling your speech so that you can monitor the patient. Don't forget to tell the family because sometimes the patient won't even recognize it, but the family or their visitor, they will. Policies, you have to address how frequently and how you're going to do this monitoring and taking into account all of those risk factors. Which resource you use to monitor. Now, these mainly focus on your narcotics that could affect their somnolence or their respiratory status, whichever one you use is up to you. They just list out a few of them, whether it's Richmond, Pacero, whichever one. Just make sure it's consistently used throughout the hospital. So if staff have to rotate, they're getting the same information. Of course, we document it. They talk about this extensively in the records section, and that specifies what content is in there. And it mentions in here, all orders, notes, treatments, medication records, anything to monitor the patient's condition. We document after we administer. If we advance document, it's inappropriate and could result in errors. In other words, nurses at the station gave 75 milligrams, Demerol IM, da, da, da, da, go down to the floor and the patient is kind of still out of it and not very awake. So the nurse just makes based upon his or her assessment. I think we need to cut back this narcotic a bit and only gives 50. We've got it already documented at 75. That's what they're talking about. The surveyor will verify your policy and procedures. Number one are there, and they've been approved by the medical staff and governing body. They will verify approved policies cover who can administer medications. They will make sure the nurse is practicing within their scope of practice. And if somebody else administers, same thing. They're following state laws. Any federal regulations that may prohibit, say it's a narcotic and a certain non-RN cannot administer it. They will look at your hospital policy, your bylaws, your rules and regulations. So they're very serious on medication administration. They will make sure you've identified those medications that can be put on a timing schedule. Those that cannot, those that are eligible, those that are time critical. They will verify time requirements don't exceed those limits, one, two, or four hours. And that they describe what are the requirements for time critical medications. Also, does this policy apply across the hospital or is it unit specific? They're going to look at a sample of medical records. You can tell medication administration is a very long segment within the nursing section. They're going to look at your records to see who administered it. Did they follow the orders? Remember, that was one of the deficiencies that some of these orders weren't carried out accordingly. Was it the right med, patient, dote, route, and timing? And was the order still in effect when it was administered? And think your antibiotics here. Do you have that automatic stop order? And yet we're still administering the antibiotic. They'll look at standing orders. They want to make sure they comply with those requirements. They're going to stand around and watch and prepare and administer medications. Did they do the five basic rights? And they're following policy on administration. Did we have to assess the patient? If so, was the assessment completed? Those at risk or high risk medications, did we monitor them for any adverse effects? And do the staff know what do you do in the event of that adverse event? How are you going to respond? They talk to nurses. They want to make sure they understand the policy and timing. Can they identify what's time critical and what's non-time critical? What are the requirements for timing of medications? They also look at standing orders. Do they also comply with all these requirements? So under medication administration, 405 is a very long and involved tag number in Appendix A. Moving on to a physician order. We know we have to have an order for any of our drugs or biologicals. How we do that, it's up to us. We can use pre-printed electronic orders. We can use order sets, or we can use protocols. Again, the one exception for a written order is that flu and Pneumovax. That's where you can use your protocols and it doesn't need to be authenticated before it's administered. Otherwise, yes, any orders for medications are documented and signed by that practitioner who's allowed to do that. That can be based on a couple of factors. State law, your hospital policy and procedures, your medical staff bylaws, because that could include non-MDs like dentists. I have in there tags 63 through 68. Again, that's in the acute manual. That's in the medical staff section and it talks about other qualified providers. Physicians can write them, and of course, if allowed, your advanced practice providers can write medication orders. They included standing orders here in this tag number. Nurses, anybody else authorized according to state law, your policy and procedures, they can give these medications using standing orders before the physician actually sees the patient. Now, CMS calls this whole set of, however you wanna call them, standing orders. That could be, excuse me, order sets, standing orders, protocols, whatever you wanna call. They call them standing orders. The standing orders have well-defined scenarios that involve medication administration. And they still have to sign off on them. Don't get me wrong. They still have to sign off on these standing orders, date and time them, but they're here to help administer care quickly and efficiently, like chest pain. Okay, we're gonna give an aspirin, we're gonna do an EKG and get this patient rolling. Or asthma, they're gonna be able to give Abutero, Atravent. Code team, they use standing orders in their code teams, like their ACLS drugs. Timing should not be a barrier when you've got an emergency going on. So that's standing orders. You have them all the time. You probably have them in your units, where here's the standing orders that if a patient experiences such an episode of ventricular tachycardia, this is what you can do. And it's nice because the nurse can do it. And of course they notify the physician after the fact. But again, we don't wanna stand in the way of trying to get ahold of the physician, get a verbal order, whatever it has to be, in order to evacuate to emergency care. Verbal orders, if you're going to use them, try and use them infrequently because it's a patient safety issue. Never for the physician's convenience. So if they're standing there, give them the keyboard, give them the chart. In an emergency, the person's not there and you have to have an order. Okay, you can use verbal orders. There are four items you wanna include in your policy. Limits on use, like not for chemo. Elements for a complete verbal order. Name, who's taking it, who received the verbal order, et cetera. Protocols for clear and effective communication, i.e., VVAP, readback. And then how are you going to identify that practitioner who's giving that order? Who is going to make sure, yes, indeed, they're the ones to give them? Are they on call for their partner? Who can accept them? That's what your policies have to address also. Is it only RNs or can an LPN or someone else take that verbal order? The state and federal laws have to permit that and your policy and procedures. Document the order in the chart as soon as it's done. In the medical records chapter, I wanna just kind of put this out there because it is so involved with verbal orders. There are two requirements affecting verbal orders. They're not in this nursing section, but it still affects them. Authenticated based upon state laws. In other words, what's the timeframe from when the nurse gets that order, the verbal order, whoever takes it, until the practitioner has to sign off on it? If there is no state law, get it as soon as possible, like the next time they see him. Write it down and repeat it back. Again, that's in the medical records chapter. I did wanna point that out because again, it's not nursing, but it affects how nurses handle them. Other practitioners, they can sign off on them. They can order them if they act according to state law, policies, and your bylaws. And when they mean state law, can a physician assistant sign off on that physician's order or not? Does the state scope of practice permit that? Now, that was new as of 2020, they did update that. On blood transfusions, IVs, following state laws and your policies, before there was a laundry list of training that CMS spelled out had to occur before a nurse could hang her blood or give IV meds. Well, they took it out because they realized, hey, that's part of your basic nursing training. And of course, we know they have to be competent to do all of this. So that's why they took them out. Just watch your scope of practice in your state law who can administer either one. And so you have to have policies approved through the medical staff. And of course, staff have to follow that. For blood transfusions and IVs, make sure they're the right vascular route. Are you gonna allow it through central lines, peripheral and imported port? How are you gonna permit that? What meds can also be administered through those? Trace the line, make sure you're using the right route, that it's the right IV line, that there's no incompatibility with the medication already in that line. And of course, programming of the devices. Those of you who've worked in some of these units, you know, you've got four or five medications hanging and you don't want to interact inappropriately with that medication. Of course, we have to monitor the patient for side effects because it happens so much faster. And monitoring include those assessment of risk factors. Those with renal failure, they're on Vanco, you base that dose upon their lab test, or genomicin, watch those peaks and troughs. Policies need to address fluid and electrolyte balance and those on higher meds, including opioids because the issue with sedation, over sedation. Risk factor, these are just for those on opioids. Snoring, maybe they're opioid naive. Increased, maybe they have habituation and we have to have increased doses. Longer length of time for anesthesia. We really have to be careful because there could still be a bad holdover from that general anesthesia. Now we're giving them opioids to further depress their respiration. Or other drugs like benzos that can affect their respirations. Any preexisting pulmonary cardiac disease, thoracic, other chest surgery, abdominal surgery that could impair their ability to take a really nice deep breath and cough and ventilate. And also if they have a chest tubes, chest tubes hurt and that's why they may not want to be taking those deep breaths. So keep those into mind, especially with your IV opioids. They do, not only ISMP, CMS, everyone recommends use that standardized sedation scale. So that one unit using it, the next unit is using it. These are the blue boxes. They're in the regulation itself. If you don't use these, you're not cited. You're not, but there's really good resources for you in there. Also the Anesthesia Patient Safety Foundation, they have some really great recommendations and especially with opioids and IV opioids, how we assess that person and what steps we need to do. They include continuous pulse ox. If the patient's on supplemental oxygen, entitled CO2, because they'll react faster. Monitoring system, so that if this patient's SATs are starting to go down or entitled CO2 starting to decline, why is that happening? That there's some way we can alert the staff and then also an escalation protocol that if the nurse taking care of that patient can't get in there, you have that timeframe set in. Okay, nurse number two has to go in and check that patient. I think 60 seconds is a little too long, but I'll leave that to your experts to determine how long, what's that timeframe from when nurse one was notified and nothing happened till nurse two is notified. And then our third, fourth question. So I think we're good on time, Lindsey. We sure are, and I'll go ahead and get that one up here on the screen. Okay, so hopefully you all will see this now, but it says, our hospital permits the following personnel to administer blood and blood products, and you can check all to apply to your organization here. Physicians, MDs, NDOs, nurse practitioners, midwives, physician assistants, registered nurses, licensed practical nurses, or possibly not sure who is or is not allowed here. Okay, and there is, I think one question here that says, if an RN forgets to document administration, how long do they have to go back and document, or is it PMP specific? That's specific to your facility, yeah, it is, because they may say, some will allow 24 hours, because, yeah, you forget, you go home and you get home and go, oh, I forgot to document, that they can allow. Two weeks is a little too long, but yeah, I would work with their in-house counsel, risk manager, that's always a good one to know what's the maximum amount of time that we're going to allow that to occur, that post-dating of that administration. Okay, I think that is the only question I see pending here. We've gotten some good results come in. I'll go ahead and end that and share those results there. All right, so yeah, it's pretty much across the board who can, okay, a couple of you do have LPNs, all right. I'm not saying, it's just, I was just kind of curious on who allows it. Sub-blood transfusion, we know we have to have the right patient and the right product. Under CMS, their standard says you have to have two qualified people to do this. One is the person who is actually administering the transfusion, qualified means according to state law. Do they allow that second person to administer blood within your hospital? Joint Commission, National Patient Safety Goal. They say you can have one person if you're using barcoding and CMS signed off on that. They said that's fine, that will be acceptable, but you must use barcoding if that is the situation. You document your monitoring and policies include how frequently, what you're monitoring, and then how do you identify and report any reactions? Because the staff have to know what are they looking for when they're administering this blood? That means they're competent in venipuncture. Can they insert that size needle in order to be able to administer it? They're trained in early detection intervention, not only for blood reaction, but opioid over sedation. Document their competency. Make sure nursing education knows this because they have to be the ones responsible for that and that staff know their policy and procedures. They will talk to staff on different units who give IV meds, give the blood transfusions. Do they know about venipuncture technique? What size needle do you have to have? How do you safely administer this medication? How do you maintain their fluid electrolyte balance to make sure we're not wiping out maybe some of their potassium or sodium or not giving them enough? How do we assess them for IV meds and then appropriately monitoring them? How do you detect, identify, and then do that early detection? What if they're on a PCA pump for morphine and they're getting more and more somnolent? Maybe you need to shut that thing off for a while and get a hold of the physician and find out what's going on. Is that too much or is the pump misfiring? They will also go around to see if there's any blood transfusions happening at the time because then they want to talk to the staff on competency, not only IV meds, but administering blood. They are encouraged to watch staff hang blood because what they're looking for is first off, safe injection practices. Did they wipe off everything? Are they wearing gloves? Are they securing the line? Was it the appropriate access? Are we watching the patient for any adverse reaction? Did they correctly do their checks for that patient before they hang the blood and start to administer it? Are they doing the appropriate checks? Was the proper people involved? Did they use barcoding? So they do observe those things being done very carefully. Then we have to report our reactions and you have to have a procedure for doing so. There is actually a tag number in the pharmacy section that affects nursing and it talks about reporting errors. But for the survey here, they want to ask how do you report an adverse reaction or an error that does occur? They may want to see your incident reports or something else that you put through your QAPI. And then they want to see your incident reports on how to handle these. On reactions, have a procedure so that when they know or when it happens, what do they do? Usually an incident report. Just make sure those are hopefully getting into your QAPI. We know transfusion reactions can be life-threatening and the guidelines, the interpretive guidelines actually talk about the symptoms of a reaction. Everything from chills and fever to respiratory failure and death. So that's nice that they did include it in there. And they use all the information based upon the expert societies. Have a policies to make sure transfusions or reactions are reported. We need to know this stuff. And immediately to the practitioner, make sure it's documented appropriately in the chart and how they report it to the QAPI program. If these really need to get in there. Was it an error in barcoding? Not necessarily a person's error, but something happened. That's why it needs to go through QAPI. Then I combined these last two tag numbers addressing medications because they pretty much overlap with each other. And it's self-administered or home medications. You can allow a patient or their caregiver or it's appropriate of course, to self-administer medications. Now, of course, this includes any hospital issued meds or if they bring them from home like an inhaler. It has to be defined and specified in your policy and procedures that yes, you're going to allow this to occur. So this is what must be in those policies. You have to have an order. The practitioner has to order, may take their own Atrevent as at home. Can leave it at the bedside for self-administration. We have to be able, and there must be a process to assess that patient's capacity. Are they competent to administer their own meds or does someone else need to do it? We have to instruct the person how to give safely. Do that old see one, do one, teach one routine. Or I'm going to show you how to administer this medication. Then I want you to show me back, do a repeat demo. And then I want you to do as though I'm the patient and you train me because then you'll find out if there's any gaps. Another thing in the policies, how are you going to secure that medicine? Will it be kept at the bedside? If so, is it going to be in their bedside drawer? Is it going to be put away at the nurse's station because of the potential for misuse or loss? And then documentation when it is self-administered. That the patient, whoever administers has to be aware that they need to tell staff, nursing. I gave him two puffs of his inhaler at this time. It is an optional, you are not required to do this, but it may help some patients. I mean, especially like stuff like hemorrhoid cream. It can be very beneficial to have that right there so they can self-apply it. Usually this is inpatients, but it may be helpful in outpatient like observation. Maybe you have someone who is there for infusion therapy and it's an outpatient service. Sometimes you can expand it to those areas. Teaching them can help avoid those readmissions, return to ED. To me, it's all part of medication reconciliation. If they're going to be doing this at home, have I adequately trained them to do it safely and correctly? The nurse may need to supervise it when it does happen. Include when you have to have nurse supervision for self-administration. What meds are just simply off the table? We're not going to allow that as part of self-administration. Nursing, pharmacy, they collaborate on development of these policy and procedures. And the surveyor will very carefully assess. They want to make sure the standards and the policies, everything follows along that they are being met. Like for example, are you going to keep your nitroglycerin bedside if you're in a coronary or a coronary step-down unit? And if so, how are you going to secure that and how are you going to document when it was given and that the patient was properly assessed? Maybe not. Again, that's up to you folks on how you want to handle it. Okay, we're now going to move to critical access. Again, you don't have a separate division within your manual. It's part of the provision of services. Now there aren't very many tag numbers and quite honestly, several of them just follow what is in the acute. So I hope you had an opportunity to hear these also. You meet the needs of the patient. You have to have an RN, either provider assigned care to each patient based upon what that patient needs. And what kind of staff do you have? What's their qualifications? What's their competency? It has to be well-organized and you have to have someone who is responsible for that nursing service. It is expected to be an RN. Not required, but it's expected to be one because they develop policy and procedures. They're responsible for the overall management and evaluation of care that's being provided. That means policy and procedures on care, supervision of staff, and ongoing review and analysis of nursing care. Agency nurses, just like with your acutes, they have to be oriented and supervised. You have to have an RN, an LPN, or clinical nurse specialist on duty whenever you have one or more inpatients. So here you have a little bit of difference between your acute hospitals. For acute, it has to be an RN. Here you can have a licensed practical nurse, clinical nurse specialist. You have to make sure it's appropriate for your outpatient services, enough supervision and non-supervision personnel to meet needs. They have to be competent, educated, trained, oriented, and of course licensed. They have to know the policy and procedures and there has to be a way to assign and coordinate nursing care. What are you going to give to particular patients, to particular nurses? They will also interview an RN. They want to ask, how do you determine the needs of your patients? How are staff assigned? Do you have a way to make sure that this nursing care meets the patient's needs? How do you train your staff? How do you orient them? How often does that occur? Who's responsible for it? Is there documentation of that orientation? They will watch nursing care. Again, they want to make sure there's enough staff to provide safe care. They'll look at your staffing schedules. Are they following policy and procedures? And do you have enough for them? They will look at your personnel folders. They want to make sure nurses, first off, are licensed and have any mandatory advanced training or education that's needed. And again, even though the state doesn't require continuing ed, you yourself, your hospital, can mandate that. The surveyor is going to look at assignments on at least one inpatient unit, the ED, and outpatient. On assignments, they want to make sure an RN is making that assignment. Did they take into account what's the complexity, the acuity of that patient? Is there supervision of their performance of the staff and agency nurse, if they happen to have one, of course? Are you familiar with your policies and procedures? Did they show you where to find them? Do you know where they're located? Do you know who you can go to if you have a question? An RN, or if your state permits it, a physician assistant has to supervise and evaluate nursing care for each patient. That includes not only inpatients, but those who are in swing bed. So they did expand that scope. Care is provided according to what the patient needs. And the plans don't have to develop for outpatients. But of course, we follow any standards of practice. So think of those who happen to be in observation. You don't have to do a care plan for that patient in observation. They will look at staffing plans. Again, I mentioned that. They want to make sure there is someone supervising and evaluating care for each patient. And then they will talk to that supervising nurse, someone who's evaluating the care. How did you do it? What were you looking for? Have you done this before? Were there any concerns that you had? And so what was the next step that you took in evaluating that care? Likewise with medications, drugs, and IVs, under the supervision of an RN, physician, or PA if the state allows that. Signed order, and they're written within the acceptable standards of practice, consistent with both state and federal laws. And then any required policies, they're very similar. It does mention multiple resources on medication administration. The required policies, who can administer, having that signed order. Same for verbal and standing orders, and the minimum content. Make sure there is compliance, that our staff is safe, they're training. Whether you're going to allow self-administration, again, totally up to you. And the content of the order is the exact same under the acutes from the name, any other additional information you have to have to the name of the prescriber. The regulation itself does say we have to have a written and signed order, but we are not precluded from using verbal or standing. Just the practitioner has to authenticate it. And at a minimum, it's the same thing. When can you use a verbal order? What mechanism to establish the identity? What are the elements of that verbal process, like a readback? Who can receive, who can act on, and then documentation. And then finally, the standing order, same thing. There's a process to develop them, approve them, monitor them, and update them. When can staff administer them? At Blue Box, they're the same for the acutes, for verbal and standing orders. There is nothing. They are encouraged to at least include these in your policy and procedures, for standing and verbal orders. And that includes that host of pre-printed or electronics. These are predefined clinical situations for use with annual review and any updates. And then as far as any additional policies, it's the same as Appendix A, self-administration, basic staff training, timing. What do you do if it's Mr. Late? IV meds and blood transfusions. Monitoring your patients, getting IV meds so that we know we're not over sedating them. And then of course, they have to have a care plan. Just like the acute, you have to have a care plan for every patient. Starts in admission and you keep it current all the way through discharge. And then finally, look at your interventions. It has to be part of your record and still have to have a care plan, even if it's an interdisciplinary. I do have some sections that also impact nursing. This is outside the manual. I've listed them. It's everything from a copy of the rights, advanced directives, grievances, history and physicals, medical records, lab services, look back, utilization review, honestly, pretty much everything and within both Appendix A and W. So I know we're at time, but here's a very quick situation. Just would like to get some input. We have a patient admitted for dehydration and flu, really poor nutrition, history of alcohol abuse. He doesn't like taking medications and he's admitted taking medications that he's had for quote, some years, end quote. He also says, I wanna take my own meds I brought in from home because I wanna save money. They're in one bottle, of course, and you have no idea how to identify them. What do you do? What would you advise the hospital to do in this situation? Do you say, nope, confiscate them? Do you send them home with someone because you can't identify what's in here. Tell them the danger of taking them, work with pharmacy, maybe they can identify them or maybe not charge for medicines. What do you do in that situation? So thank you for putting it up. I know again, we're a minute past, but Lindsay, I'll leave it to you to see if there's any more questions. Yep, no problem at all. And I do see some pending responses here to this discussion question. If you have any additional comments or questions, you can of course go ahead and type those into the Q&A option or the chat. I don't see any pending questions at this time, Laura. So while they are still putting in this final discussion, I'll just give you a couple of last minute comments here that you will all receive that final email for that follow-up email, excuse me, tomorrow morning that will come from educationreplyatzoom.us. And so because those emails do come from the Zoom email address, it very well may get caught in your spam, quarantine, your junk folders. If you don't see that in your inbox this morning, I would first encourage you just to check those additional folders. But if you'd just like to go back and access the recording of today's session, again, you can just use that same Zoom link that you used to join us for the live presentation today to also access the recording. Just remember that the recording is available via Zoom for 60 days from today's date. And once you click on that Zoom link, it will ask you to enter your information for an email to come to us for approval of that recording access request. We do typically approve those requests very quickly, but we ask that you just give us one business day to grant those approvals once that we verify your information there. And then also included in your email tomorrow morning will be a link to the slides that Laura did present for us today. I did go ahead and provide that link there for you in the chat, have as a resource now as well. Okay, I'll go ahead and end this poll and share those results there. Laura, if you wanna give some final comments on this discussion and if there are additional resources. Yeah, this was a tough one because this was a very stubborn individual. Now, this particular hospital did just finally say, we can't have you doing that, I'm sorry. And they confiscated him. They did, they gave him back, you know, when he went home saying, this is not a good idea and really wanted to destroy him, he was raising such a fuss, but they did confiscate him and say, you will not be charged for in-house use of our medications. By the way, there are roughly several slides after this. These are strictly resources, you don't have to use them. I have like 23 of them. If you have a question on a particular slide, please reach out to Lindsay. She will get me the question and then I can follow up very quickly with you if there is a question. With the links provided, you have to copy paste into your surf engine. It won't automatically connect, unfortunately. So thank you, Lindsay. And again, thank you for those who stayed with us for the four minutes, I apologize. No, perfect. Turn it to you. Absolutely, thank you so much, Laura. I did just put that email address there for you in the chat. If you do have additional questions, as Laura just mentioned, you're more than welcome to send those to education at gha.org. And I'm happy to get those over to her. And we're so thankful for her always being so willing and thorough in her responses. I know you go above and beyond doing that, Laura, and we greatly appreciate that. Thank you. Okay, I don't see any pending questions at this time. So thank you all so much for joining us today. Thank you, Laura, as always, for your time and the information that you shared with us. We look forward to having you all back with us for future sessions. I hope you all have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay.

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