Resident Care Flashcards by Ray Lauritzen

Residents must receive the care necessary to meet individual ____,____,and _____ to achieve and maintain their highest possible level of independence, self-care, and self-worth and well-being

physical
psychosocial
rehabilitative needs and assistance

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Provision of care must be _______

documented in the health record

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the ______ is responsible to coordinate medical care in the facility

medical director

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Residents must be provided a safe, supportive, comfortable and ________ environment

homelike

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Residents must be provided _____ and _____ to exercise choice over their surroundings, schedules and health care

freedom and encouragement

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Residents must be provided the opportunity to be involved with members of their community _____ and ____ the nursing home

inside and outside

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Residents must be provided treatment with ____ and ____

dignity and respect

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for residents at risk to develop decubitus ulcers while in the facility (nosocomial) the facility must: Assess the potential for _____

skin breakdown

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for Decubitus sores the facility must provide \_\_\_\_\_\_\_\_\_\_ the ulcer develops in residents who are 
1 underweight
2incontinent
3dehydrated
4disoriented 
5unconsciousness
6have limited mobility

preventative measures before

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For all residents with decubitus ulcers, the facility must a. develop a _______ plan to alleviate the condition b. provide active treamtent in accordance with the treatment plan c. evaluate each residents progress and treament at ________ and revise the treatment plan as needed d. provide proper nutrition and hydration to promote healing and prevent further breakdown

individualized treatment

least weekly

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in accident prevention and attention the facility must ______ causes of accidents _____ the resident’s response after an accident and ______ and ___ an individualized plan to prevent future accidents

investigate
monitor
develop and implement

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For residents at high risk for accidents, a facility must ________ to prevent common accidents before they occur

identify any risks in the care plan and take reasonable precautions

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if one accident has happened and you fail to take reasonable actions sufficient to reasonably minimize the possibility of another accident you can be cited for _______

substandard care-actual harm

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the ______ want to see that you tried to individualize precautions instead of standard protocol ie: bed alarm and cushions on side of bed

surveyors

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Residents at high risk of accidents include the blind, the deaf, and those with ________ (5 answers)

seizure disorders
had an accident in the last 6 months
are totally confused by ambulatory
are new amputees
are receiving psychoactive drugs

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the care plan for each individual should address precautions for possible accidents or _______

accidents thats may have already happened

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For residents with behavior problems the facility must:
a. note the behavioral problem and evaluate it in the initial assessment b. develop and implement a _____ treatment plan c. develop and implement a _________ plan d. obtain a mental health evaluation e. evaluate the residents progress and revise the plan

individualized

behavior management

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for residents receiving behavior modification drugs, must indicate in nurses’ notes both _____ and/or ______ effects and alternatives to the drug

positive and/or negative

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For residents with contractures upon admission, the facility must have ____,_____ and _____restorative nursing intervention

noted the problem
evaluated it
undertaken

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For residents with contractures that occurred with in the facility, the facility must have ________ the range of motion and/or repositioning was performed before the contracture developed

documented

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if the resident refused treatment or preventive measures concerning contractures the facility must have

informed consent (refusal was explained to resident)

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Treatment and preventative plans for the residents for the potential to develop contractures must be _____ and _____ at least ____ as needed

reviewed and revised

annually

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Must assess each residents ambulation potential at least ____

monthly

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For residents requiring devices and/or personal assistance to ambulate, the facility must ___ and _______ assist resident to obtain appropriate footwear and provide assistance to move and transfer

provide and maintain devices in good repair

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for residents with an indwelling catheter, the facility must evaluate appropriateness of continued use at least ____

monthly

when using an indwelling catheter you must _____the reason for incontinence and ____the potential of bladder retraining and implement it

assess | evaluate

______any physician order for irrigation or catheter replacement

Implement

concerning Indwelling catheter care: For residents exhibiting signs or symptoms of _____the facility must have _____, ______ and implemented the treatment plan

UTI notified the physician obtained orders for treatment (prophylaxis)

the facility must do the following for residents with weight change: a. evaluate and determine cause b. individualized care plan c. observe food and fluid intake and encourage to eat d. _______ e. document nourishments and if consumed f. provide assistance in eating g. assist in obtaining dentures or dental care

provide choices of foods to meet personal preferences and religious needs

each resident must be admitted by a _____ and have continuing care under _____ of a physician

physician | supervision

the admitting physician must provide a schedule of visits to meet resident needs no less often than ______

every 6 months

acknowledgement of visit schedule by resident or authorized representative must be documented in ____

health record

Telephone orders must be received by a physician, Licensed nurse or other appropriate disciplines and entered in the record within ____

2 weeks

the facility must assure the _____ authenticates medical histories and physical examinations completed by other authorized personnel

attending physician

the facility must assure that a _____ authenticates dental exams and histoies completed by other authorized personnel and ____ dental treatment records

licensed dentist | signs

The _____ must write a progress note following _____ and at least ______ provide a written evaluation of residents current medical status compared to previous year's status

attending physician each visit once per year

All drugs and therapies ordered by physician must be _____ by diagnosis indicating use of those drugs and therapies

supported

the facility must have ______ developed by the _____ to coordinate and designate responsibility when more than one physician is treating a resident

written policies | medical director

____ must have a written agreement with a physician or medical group to serve as such to the facility

medical director

the medical director is responsible for _______ in the facility and for systematic review of quality of care

overall coordination of medical care

the medical direcor is specifically responsible to a. be a _____ btwn facility and admitting phaysicians b.___ and ___ resident care policies and procedures c. _____ rules governing conduct of physicians admitting residents to facility d. develop a procedure for ______ when physician is unavailable e. ____ accidents and hazards F. _____ in pharmacy advisory committee deliberations

``` liaison develop and review establish emergencies review participate ```

must have a _____ formally organized to provide effective care and written job descriptions

nursing department

must employ a full time _____ who is a _____ to direct facility nursing care

Director of nursing | Registered nurse

must have at least ______ on duty each shift

1 registered nurse

each resident care unit must be staffed with at least ______ on each shift

1 licensed nurse

an intermediate care facility must be staffed with at least __ full time _____ or _____ who is on duty on premises on day shift __ days per week

1 licensed registered nurse licensed practical nurse 7

a facility using a licensed practical nurse as DON must provide at least __ per week of consultation by _____

4 hours | licensed registered nurse

must provide a minimum of ____ per resident _____ in facilities of ___ residents or more

2 per day 60

The DON, Staff development coordinator, and other supervisory personnel NOT providing direct resident care must or must not be computed in staffing hours

must not

True or false: | all nursing assistants and other nursing personnel must function under the direction of a registered nurse

TRUE

If a long term care facility operates out of more than one building, must have staff on duty _____ in each building sufficient to meet resident care need

24 hours

Nursing procedures must be evaluated and revised no less often than ____

annually

___ must be administered per ____

medications | colorado law

must have _____ nursing procedures

written

must provide ___ and ____ necessary for an effective, therapeutic and rehabilitative nursing program

supplies | equipment

must provide residents ____,____,____, and ____ that fit properly

walkers crutches canes wheelchairs

must have ___ resident care policies approved by ______

written | governing body

true or false: residents must be dressed, encouraged to be active, be out of bed for reasonable periods of time each day and encouraged to eat in dining room

true

Medications must be ____

clearly identified

staff must verify identification of medication when ____ as well as when it is _____

prepared | administered

must only administer meds as ordered by ___

physician

meds must be administer in a form that is ___tolerated by resident

easily

must or must not mask a med or alter by crushing or dissolving, if to do so would be hazardous and not without first informing ___ or ____

must not resident responsible party

meds that are prepared but unused must be ____ of in accordance with state law and facility written procedures

disposed

all administered meds must be recorded in residents health record indicating ___, ___,___, and __ date and time and person administering meds

name strength dosage mode of administraion

residents ___ self administer meds by order of ___ and under guidance of __ or ___

may attending physician RN or LPN

if facility policy permits meds to be kept at bedside the ______ must approve such meds and must assure that each med is ordered by ____ is used properly and stored securely

pharmaceutical advisory committee | physician

Drug reactions and significant med errors must be reported within ___ to residents physician

True or False: a call to office or answering service meets facilities responsibility to provide emergency care

false

in med error the residents condition must be monitored for ____ and observations documented in health record

72 hours

If a resident is administered psychoactive meds he must be evaluated for symptoms of _____ at least ____

Tardives Dyskinesia | every 3 months

Physical restraints must be monitored every ____ for proper positioning and blood flow

15 min

The physical restraint must be removed every ___ during waking hours for activity, food ect.

2 hours

for residents physically restrained the medical record must document ___ review of restraint and evidence restraints were removed

monthly

Whenever restraints are used a resident must have a ___ in easy reach

call signal switch

in an emergency of danger to self or others a ___ or ___ may order a physical restraint. the nature of emergency must be documented in ___ and a physicians order for restrain must be obtained no later than ___

RN or LPN health record 24 hours

a chemical restraint is a med to __ or ___ behavior

alter | control

it is not a chemical restraint if ___

med is used solely or primarily to treat medical condition

through the nursing assessment if the need for a safety device is ongoing a comprehensive assessment mst be completed no less often than ___ after ____ and then at ___ and then ____

first 24 hours application of device end of the week monthly thereafter

at least every ___ residents with safety devices must be monitored and documented

2 hours

residents with safety devices must have a ___ or __ within reach

call signal switch | similar device

___ must identify, plan care for, and meet emotional and social needs of each resident to enhance resident psycho-social health and well being

social services

__ must assist residents and families prior to admission

social service staff

social services must ____, ____ and ___

plan discharge, arrance support services, coordinate transfers (other than medical transfers)

social services must participate in resident assessment and care planning and update assessments and care plans at least ____

every 6 months

Social services must record each residents social history in the health record and review it at least ____

annually

Social services must record progress notes in residents health record at least ___ for the first ___ and at least ____ therafter

quarterly 6 months semi annually

The facility must provide for social services staff ____, and ___

suitable space | telephone for confidential interviews

social service space must provide: ____, ____, and be ____

visual and auditory privacy locked storage for confidential records accessible to non-ambulatory persons

must offer activities that promote resident ___. ___. ___ and ____

physical social mental and intellectual well being

activities must stimulate participation but no resident must ____

be compelled to participate

each month activities must include at least one from each category: (5 answers)

``` social/recreational intellectual physical spiritual creative ```

must provide activities ___including at least ___

7 days a week | 1 evening per week

activities must be provided on _____

weekends each week

must post a ____ visible to all residents and families indicating date and time

monthly activities schedule

must retain ____ and maintain in location other than health record

activity attendance records

True or False: | Must assist resident to attend religious services of their choice

True

True or False: Must honor resident requests to see their clergy and provide private space for visits

True

must make available supplies space and equipment to provide books, current newspapers games stationery radio and television

yes

Brainscape's Knowledge GenomeTM

Resident Care Flashcards

Brainscape's Knowledge Genome^TM