Bigger than a bread box.
Subject: Long-term care of the sick (Services)
Long-term care of the sick (Laws, regulations and rules)
Nursing homes (Services)
Nursing homes (Laws, regulations and rules)
Author: McCoy, Kathleen T.
Pub Date: 09/22/2009
Publication: Name: Tennessee Nurse Publisher: Tennessee Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2009 Tennessee Nurses Association ISSN: 1055-3134
Issue: Date: Fall, 2009 Source Volume: 72 Source Issue: 3
Topic: Event Code: 360 Services information; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8050000 Nursing & Rest Homes; 8366000 Homes for Aged NAICS Code: 623 Nursing and Residential Care Facilities; 623312 Homes for the Elderly SIC Code: 8051 Skilled nursing care facilities; 8052 Intermediate care facilities; 8059 Nursing and personal care, not elsewhere classified
Geographic: Geographic Scope: Tennessee Geographic Code: 1U6TN Tennessee
Legal: Statute: Nursing Home Quality Reform Act of 1987
Accession Number: 208458687
Full Text: I was hearing something that stirred some very deep convictions. I had received the call in the beginning of my office hours at a community mental health clinic, where I was currently practicing in the Mid-West. It came from the nursing staff of a rural Skilled Nursing Facility (SNF). The clinic served the SNF through its celebrated Geriatric Outreach Program--work I had become well versed and comfortable in--Psychiatric Mental Health to long term care (LTC) residents and facilities.


A little history is needed to flesh out the background of how LTC is governed. Behavioral health services to SNFs have been greatly affected by the advocacy intended through the Omnibus Reconciliation Budget Act of 1987 (OBRA; the Nursing Home Reform Act) and resulting in OBRA Regulations. To make this very simple, the Nursing Home Reform Act's targeted purposes are to safe guard the vulnerable elderly residents to receive respectful care, have maximum quality of life and protect these residents from receiving unnecessary procedures/treatments (including medication).

OBRA regulations are chiefly enforced by:

* Defining SNFs as entities which are mandated to position a Registered Nurse 24/7 over nursing care in all SNFs as an advocate of residents through coordination of nursing and other related patient care services including nursing staff development.

* Providing recommendations and oversight mechanisms for services including medication management to promote quality of life and prevent overutilization.

* The Presence of Ombudspersons as local oversight agents regarding regulations of OBRA.

In short, LTC facilities wanting Medicare or Medicaid funding are able to provide services so that each resident can "attain and maintain her highest practical physical, mental and psycho-social well-being." Without compliance to OBRA regulations, LTC facilities stand to compromise patient care and lose funding support. It is very important to note the central role of nursing in LTC as recommended by OBRA regulations.

Back to my unnerving phone call.

The call was nothing unusual, but there was a little spin that I caught, riveting my attention. Orders had been written to cover a resident's symptoms, and these were appropriate and well within OBRA Recommendations. The patient was currently in distress and in distress all night. I had attempted to avoid such a situation with my orders which were not carried out. Why weren't the orders followed? Interestingly, the previous night, the night that the patient's symptoms became problematic, a medication aide was delegated to give medicines and due to her not being a licensed nurse, she was not permitted to make an assessment or a decision when the patient's status had changed; therefore, the medication was held until I was reached. Nursing staff did not intervene since it was perceived to be the medication aide's job to "give meds."

This curious turn generated some questions.

* Because the patient resided in a SNF facility, wasn't a communication link with nursing staff established when "nursing process" was needed?

* Why didn't the nursing staff simply step in and provide the assessment and appropriate action on behalf of a patient need? Did they think they were off the hook or even forbidden to intervene because of a delegated task?

* Since when was the process of providing medication as simple as "just giving" medication without nursing process?

* I was not even aware that the role existed or how it worked. This knowledge was underneath my personal radar; how did that come to be?

I bit my tongue, addressed the situation on behalf of my patient, shook my head and thought to myself, "This would never happen in Tennessee."

Never say "never"--this now has happened in Tennessee.

The recent passage of SB0009/HB1607 now provides for certified medication aides in the State of Tennessee. While limited to Nursing Homes and Assisted Living Facilities, at least there is some safety built into the limits and co-existing OBRA regulations. The potential for confusion in roles and authority is a by-product of this fundamental shift in service provision and one that all nurses, especially those in LTC settings, must be vigilant about so that nursing care will continue to be a "continuous process" utilizing critical thinking skills.

Where will this take us? Nursing care has been deemed to be an expense, one that has generated some rather dynamic solutions. Those business solutions that pull nursing process out of the equation put the public in peril.

As nursing continues to have its "tasks" delegated through increasing acceptance and adoption of new roles, let us all be very wary and be very circumspect, especially with new roles that will be developed to fill gaps in less regulated settings including school-based care and home health. It is daunting to think about the endless array of opportunities that can erode the role and function of nurses in the community.

Small changes can be like Trojan horses; every new player on a field changes the dynamics of play. Nursing practice is changing fundamentally on the ground floor and it is happening before our unbelieving eyes. Issues surrounding medication aides are new and difficult to measure because other states have little historic data to pull from to synthesize conclusions. It would be fitting for the Board(s) of Nursing to be diligent and capture data indicating the clinical outcomes of medication aide introduction in relation to patient safety. This introduces yet another concern, costs related to oversight of a new role. "This whole role sure seems to be bigger than a bread box" says one of my esteemed and very worried colleagues.

In the words of Thomas Jefferson, "The price of liberty (to practice) is eternal vigilance." It may be a good time for nurses on all levels to become more aware of "what's happening" in the legislature and to befriend their representatives.

by Kathleen T. McCoy DNSc, RN, APN, PMHNP, CNS, FNP-BC

Kathleen T. McCoy, DNSc, RN, APN, PMHNP, CNS, FNP-BC, is an assistant professor at the University of Tennessee Health Science Center, Memphis, Tenn. McCoy is TNA District 9 President.

* References available upon request to TNA at
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