Meet Nursing Home Staff
The key nurses in nursing homes include the MDS Nurse Coordinator, director of nursing, unit-based RNs and LPNs, and nursing assistants. Click each of these nurses shown below to hear them describe their roles and background. As you listen, you will be able to answer the questions below.
Director of Nursing Transcript
I’m responsible for all of the medical care that the residents are receiving. To make sure that they’re getting all their needs met, that the nursing staff is following their job descriptions, and meeting the needs of the resident. I also have a responsibility for budgeting for my department, and making sure that I stay within my budget guidelines, making sure that I stay within the state federal guidelines, survey guidelines; anything that has anything to do with the nursing care.
I hire all of the RNs; any staff that would be in a leadership role the ultimate decision for the nursing, is my decision, if they get hired or not.
When the administrator is not here, I am responsible for the nursing home, too, besides the nursing department. So, I’m second in command of the nursing home. We’re a team.
He will defer to me for nursing for instance; I can throw out an example of an admission, for the TCU, for instance. You know, he is administrator, he has to look at dollars and money, and he has to fill beds, and… but he’ll defer to me if it’s an appropriate fit. If we can make sure — because I have to look at the assessments and make sure that, that we can meet all the medical needs of that resident. And if I feel that we can’t medically meet their needs, or it’s just, maybe the TCU is just overwhelmed right now with their acuity up there, and we have to deny that admission, then he’ll be just fine with that and he’ll support my decision. He’s very supportive of me, and we do have a good relationship, I mean, he trusts me to do what I’m doing, and to make sure that I’m spending within the budget confines, we’re staffing right, we’re getting ready for surveys. He gives me a lot of autonomy, but at the same time, I also give him a lot of information on what I’m doing, too.
Directors of nursing wear a lot of hats. You have to be able to either have the answers for your staff, or know where to go to get the answers. For instance, if there’s a resident coming in that has a specific treatment, and the nurses aren’t sure of what that treatment is, or how to do it, I need to know, to teach them. Or, I need to know where to go to get the information for them, so that they have it there. It helps a director of nursing if she’s walked in other shoes. So, for me, personally, I’ve been an aide, LPN, all the way up. And, so I can relate to where they’re at at the time with their learning. But, I also have to know how to manage, I have to know how to delegate, how to work within my budget. I try to be very fair to my staff. I want them to like working here, and I want them to have everything that they need, all the tools they need to do a good job, so, if it’s increasing their education level, or just giving them some emotional support, I do it maybe the biggest thing I have to have, is the ability to be flexible, also, in my role as a director, because my day can change on a dime, and lots of patience.
I read a lot, I do some researching on the internet, talking with other DON’s, the state, Minnesota Department of Health puts out a newsletter, so you have to keep up on the regs.
I have a lot of influence relating to quality of life and quality of care, because I, that’s my job, to make sure that our residents are getting the care that they need, and their quality of life is where it needs to be and is the best possible level that they could have.
We want the residents’ quality of life to be at the highest it possibly can and so that, through teaching the aides to encourage residents maybe to do as much as they can for themselves, making sure that residents are happy, that they’re getting their needs met, that they’re getting their psycho-social needs met too, improves their quality of life.
My advice to nursing students that might want to consider a career is to come in …I always tell the nurses don’t think that you’re just coming to pass meds, because that’s not what it’s about at a nursing home. They’ve changed, over the years. You’re getting more acutely ill people, you’re getting specialties, units in nursing homes, we have a TCU here, it’s just like hospital nursing if you want that; if you don’t want that, then you can work in the households, and…but you’re part of the life of the home, here.
MDS Nurse Coordinator Transcript
An MDS coordinator position involves a good understanding of the nursing as the assessment progresses. We can determine trigger areas that need further assessment. The trigger process goes into further detail for assessment and coordination of care. The MDS also generate a care plan. And then, it is evaluation of that care plan. The government decided to also turn it into a billing process as well, so that generates our RUG, state case mix, as well as Medicare RUG, so it is a financial document as well. It also generates our quality indicators and quality measures, and that is visible in the links for nursing home compare, and it is electronically submitted to CMS, which is the Center for Medicare and Medicaid Services, and from that also comes our survey process. So when the survey team comes in, they pretty much know what they want to be looking for.
I do the assessment, I schedule the MDS assessments, and I notify the team of the MDS assessments that are due. I’m involved in submission of the MDS’s, and we submit weekly, and then submitting it’s electronic so we send the electronic submission to the Department of Health, CMS.
It is an interdisciplinary team, the MDS process, and so it would be social services, dietary, which is the dietician, then we also have activity personnel involved in that, therapy, if the person is receiving physical, occupational, or speech therapy, they have an input in that as well.
Well, I am an RN; to be an MDS coordinator, you should be an RN. I have education, further education in assessment coordination. I also have to be knowledgeable of the nursing process and procedure, I am detail oriented and organized; there are the four interviews that we participate in, and then I can meet the resident at that time. And, that’s beneficial in that I can see for myself what their cognitive process is like, if they can see and hear adequately, if they wear glasses or have hearing aids, if they have a language impairment or cognitive impairment, that’s helpful. I can see how their range of motion and physical functioning is at that time, too. So, it’s very fast-paced, and I might not be doing the day-to-day care, but I can gain a lot of knowledge on that resident from the interview and interaction.
The impact of the MDS for financial strength of a facility is based on the accuracy of the MDS assessment, and the quality of the care that’s given. Financial solvency in the facility is based on MDS completion and accuracy.
I think the MDS position is a very important role in the nursing facility, and I look back to my education as a nurse, and when I was first in school to become an RN, I had an instructor who talked about the, “Hail, the Liver”, that does multi-purposes in our body, and so I kind of look at the MDS process as the liver of the nursing home, because it has multiple functions, and it’s important functions, for the financial, and quality of our facility.
The MDS generates a quality indicator, how is our facility doing compared with other facilities in the region, and nation, We want our residents to remain as functionally independent as they possibly can, and that’s one of the things in the MDS process that we look at, if there’s a deterioration in their ability, they may need some physical or occupational therapy to regain their functional independence, to keep them at the highest practicable level of function. We also look at pain management, it’s a big part in the nursing home population, that pain may not be recognized, and it may be there if cognitive function impairs their ability to verbalize their pain, and need for medication, or interventions to reduce the pain. We also look at falls, of course we don’t want any elderly person to fall; there are very huge risks in their physical function if they fall and injure themselves.
I keep current in the MDS process by being a member of the American Association for Nurse Assessment Coordinators, also known as ANAC. I am a member in that organization, and I am also on the CMS listserv. So when there are changes in the MDS process, I am notified by an email, and then I read the email and get the education I need. I also have a copy of the manual that I keep updated, and I refer to the manual all the time, when there’s a question on the MDS process.
I get to know each resident as a whole, by the chart review that I do, and the staff and resident interviews, and as I process through the RAI process, which is Resident Assessment Instrument, that’s what an MDS is. I also use the nursing process daily to ensure the best nursing care, or quality, is given to each resident. And, I like the detail and the continuing education that I get to maintain my certification.
RN (Unit-Based) Transcript
Registered nurses are - do all the assessments: Side rail assessment, pain assessment, bowel and bladder assessment, dental, eye, MDSs, registered nurses do all the MDS’s, quarterlies, annuals, admissions, discharge…
Usually I work on an MDS daily, or a care plan, usually both. I meet with a household coordinator, daily, to see if there’s any problems, any issues, something new that’s come up, somebody’s had a fall, how can we come together as a team to help this person not fall, and keep them safe. If somebody needs therapy, maybe they might bring it to my attention, like, somebody may need therapy… I usually take care of the harder problems, issues, something that is more time consuming, I’m — usually have to work with difficult families, difficult residents, if there’s an issue within their family, if someone’s moving in, if you know, if they’re having trouble with the nurse, with their medications — usually it’s medications that I’m having to help out with. Or, if we are — you know, come together as a team and think this person is very depressed, what are we going to do about it.
I think that the elder population has a different, kind of like a set of conditions that are more common than in the younger population, such as CHF, and frequency of pneumonia, and UTI’s, and how the elder person reacts to those problems. Whereas, you know, like if you or I got a UTI, we might be, it might hurt and well, and we go to the doctor right away. But, a lot of times if somebody has - not a lot of times… If a person falls, one of the first things we think of is maybe they have a UTI. Or if they’re not eating, or they’re not drinking or they just don’t feel good, well, that’s one of the first things we’d check. A lot of times, they do not get a temperature, and if they have dementia, they might not be able to tell you what’s wrong with them, you just have to go with what you observe.
Care conference is usually the resident, the resident’s family - whoever’s invited, the household coordinator, and life enhancement, and a nurse. And if the nurse that’s working the floor that day, who usually knows the resident very well, is unable to make it for some reason, then I usually step in. Or, if there’s a difficult family, and they usually request me to come, so then I go for that. At a care conference, we discuss, like the resident’s weight, if they’re stable, losing weight, gaining weight, and why; if they take any psychotropic meds, their code status; activities they’re participating in that they like to do, is there anything else they would like to be doing; they usually discuss the food, what they like or don’t like about it, or any problems/issues that may come up.
I want them to be able to feel comfortable to come get me to help so if there’s an issue, I can see it - such as a skin issue, or if somebody’s having difficulty transferring, and we need to get therapy, or we need to use a different way of transferring for their safety. So, I like to be right there with them and…
I like my role because it’s — it’s very broad. I’m not just doing one thing. I do a lot of things. Every day is something different. I like being able to do different things, learn different things, such as the MDS.
Some advice I would give to the nursing students who would like a career in a nursing home in long-term care is to learn about dementia, and learn how to communicate with a person with dementia. You need a lot of patience, learn some of the illnesses that the geriatric population has, such as CHF, and pneumonia, CVA’s. Good assessment skills — learn very good assessment skills. Because, when you are calling a doctor, you need to paint a picture for the doctor so they know exactly what is going on with that resident, and how to treat them.
What I find most rewarding about working in a nursing home is, I like seeing people every day, seeing them happy and healthy, learning about them, seeing them smile. It — you get that funny feeling in your heart like you want to cry because you’re so happy, you feel good about something that you’ve done that day, helped somebody. Whether it be sending them to the hospital because they’re just very ill, or — if they’re dying, because this is also a place where people die. To be here and be able to keep them as comfortable as possible, and work with the families to keep them up to date, and if there’s anything we can do to — you know, sometimes they can spend the night here, if they’re actively dying, make sure they have — we bring them coffee, and lemonade, or water, or little snacks, when there’s, you know, a gathering of family. We have, after someone has passed away, we usually have like, memorial service in the house, we have prayers at bedside and the other residents from the house will come to that person’s room. That’s really nice. Like a family. That’s what I like about working here too, it’s like a family, you see your friends every day, you get to work with your friends. And I think in the hospital, you have so many different people you work with every day. But here, it’s usually pretty friendly, you eat lunch with your friends, and we can eat with the residents if we want.
My responsibility as a nursing assistant in a nursing home is to help the resident with their daily activities, show dignity in respecting them and their personal belongings, and helping them to accomplish their daily desires, in, like, exercise, or in like fun, and show interest, that I care, that I’m there to listen, and to report, like, if they have pain, to the nurse.
Some residents that can’t help themselves, like some people that have, you know, dementia, first of all, we go by their care plans, and try to read some of their history, their, what they used to like, you know, and things that, if they want to talk about their old time memory, you just show interest in them.
I work with the nurse as a team, in that our goal is to make sure that the resident’s daily quality of life is accomplished. So whatever I need to know, attending the resident, the nurse tells me, because I am the resident, the right person most time. So, whatever they tell me, whatever the patient tells me, I go to the nurse…
I need to have people skills, you know, like be a people person, and learn to show dignity for the resident, their belongings, their family, respect.
Well, you go to the school, and they teach you how to deal with this person, who is almost at their final stage of life, how to handle their activities, how to deal with their belongings, how to communicate with them, and to be able to make them comfortable, because the goal is that, the patient is the goal, in the sense that the, some of them are depressed, some of them are hurt. When you come in their life as a stranger, you want to make them to trust you, you want to make them to know that you care, and most times, communicating, giving them your smile…
If you’re going to give a resident a bath, first of all, when you come in the morning, you look at the assignment sheet, if Mary has a bath for the day, you go to her room, ask her if she wants to take a bath, “Good morning, Mary, you have a bath scheduled this morning, will you be ready for it now, it’s maybe 9:00, or do you want it later?” And then she might tell you, “Oh, yes, I’m ready for it, OK”, and then, you ask her, “What would you like to wear today?” That is if she is, you know, alright. And then she can show you what she wants to wear, you pick it up, and then you get to the tub room, you know, provide privacy by closing the door, pulling the curtain if you have one, and then make sure the water is warm. You know, you don’t want to put cold water on somebody. Make sure you have a warm blanket on her, because a lot of time, the residents are cold. A lot of them complain about being cold. And then, you just give them a nice bath the way they want it, and help them to get dressed.
You have to have that heart as a caring person. I provide a quality…well, I do that almost every day, because it’s part of my job, and as a caring person, I implement that. In the sense that I help them with their…whatever they’re interested in: their food, their proper attire, and how groomed they are, their hygiene, and…hold their hands, you know — even give them, you know, just touch them, say hi to them, and show to them - look the patient in the eyes, they like that. They feel that you care, and you’re concerned, if you’re talking to them, you know, and you’re looking them in the eyes, they feel that you’re listening. Try not to talk over them, you know, go below, maybe if the person is sitting, if there’s a chair, you can ask them can I sit by you, if it is ok, you sit, or else you can just hang down, you know, and talk to them, you know, and just give them your smile.
I work with a nursing assistant as team worker, in that we share, if I need help, let’s say if I have a patient that needs transfer who is a two-person, it’s ok for me to go to any of them and ask them to help me.
What I like best about my job is that, helping, being that I’m able and I’m blessed to be in a position to help somebody who needs help, you know, that I’m there to give a helping hand to somebody.
Question for reflection...
After listening to each of these nursing staff, consider how nursing students might be able to have a learning experience with each one. What learning objective would you have for each?