MYTH No. 1. Hands-off communication about residents transitioning from one level of care to the next should be done only by nurses.
The greatest risk for medication errors involving nursing home residents occurs during the process of transitioning from hospitals to the nursing home or back to the hospital.

Although most long term care facilities have policies that require direct nurse-to-nurse communication by telephone in addition to the use of the transfer form, there is no similar expectation for physicians.

It is critical that the treating physician in the hospital communicates essential clinical information to the physician who will be providing care in the nursing home setting, particularly if the facility physician has never treated that resident before.

In addition to reviewing the course of care, the hospital physician must review the medications, including the expected duration of treatment for antibiotics and anticoagulants, as well as justification for the use of any psychotropic agents and the rationale for continuing indwelling catheters or long-term intravenous access.

The receiving physician should also have a clear understanding of the resident’s advance directives and preferences and whether there are tensions between the resident and the family regarding goals of care.

MYTH No. 2. Reading the list of medications to a physician over the telephone that are contained on the transfer form from the hospital is an accurate and appropriate way of ordering medications for use in the long term care facility.

Without having the ability to review the hospital record or to have direct communication with a hospital provider, the attending physician in the long term care setting has no basis of knowing what medications are used for which clinical conditions or how long they should be used. Interrupting a physician in the middle of office hours to review the medications of a patient he or she has never treated increases the risk of inappropriate regimens and medication errors.

MYTH No. 3. The social worker is the most appropriate staff member to discuss advance directives.
Advance directives, particularly the use of cardiopulmonary resuscitation (CPR) and the decision to place a feeding tube, require a physician to provide informed consent, a process that includes the benefits as well as the risks of each of these procedures. Social workers and nurses lack the requisite knowledge to provide an informed consent for residents and their families. These complex discussions must be provided within the context of the physician-resident relationship and may be delegated to the nurse practitioner or physician’s assistant under certain circumstances.

MYTH No. 4. The prevention of rehospitalizations can best be addressed by improving the nursing staff’s clinical skills.
Although addressing the improvement of the clinical skills of nursing staff, particularly head-to-toe assessments and a clear understanding of vital sign interpretation, by far the greatest issue in the rehospitalization of nursing home residents occurs during “after hours.”

Addressing the need to find alternatives to sending residents back to the hospital requires that attending physicians develop protocols for their colleagues who are covering them at night and during the weekends. It also includes establishing parameters for vitals signs, specifying under what circumstances PRN (as needed) medications should be administered and being proactive about conditions in specific residents that are most likely to result in the exacerbation of symptoms leading to rehospitalization.

MYTH No. 5. People who fall in the community will not continue to fall in a nursing home.
An admissions director was overheard telling a family member, “Is your mother falling at home? If you admit her here, falling will no longer be a problem.” The causes of falls in a nursing home resident are usually multifactorial and are seldom ameliorated simply by entering a facility. The advantage of admission to a long term care facility for individuals with the propensity to fall is the fact that there are people to help them up and assess them after they fall.

The expectation that older adults will no longer fall once they are admitted to a nursing home needs to be dispelled upon admission, with the clear communication of information detailing how the facility will be able to minimize the risk of falls through appropriate interventions, rather than providing a guarantee that all accidents will be prevented.

MYTH No. 6. The use of a feeding tube will be necessary in healing a resident’s pressure ulcer.
Once significant pressure ulcers develop, a feeding tube may actually accelerate the deterioration of the wound, rather than improving the status. Tube feedings require the resident to be maintaining in at least a 30-degree elevation in bed in order to minimize the risk of pulmonary aspiration of stomach contents. The greater the elevation of the head of the bed, the greater the pressure over the buttocks and sacrum, which are the most likely sites of pressure ulceration. Moreover, the resident may have difficulty absorbing the tube feeding solution or may develop liquid stool that adversely affects skin integrity to an even greater degree than urine.

The use of enteral feedings in a resident with advanced Alzheimer’s disease has no positive effect on the quality of life.

MYTH No. 7. The process of care planning requires clinical department heads to formulate goals and object-ives for the residents during care conferences.
The process of care planning must include interventions that reach the level of the resident. In order to accomplish these goals, the care plan must be in a form that is accessible to the certified nurse assistant (CNA). The CNA must be an integral part of care planning efforts, attending care conferences and offering interventions and suggestions that are based upon actual experience of working with the individual resident.

The ability to write goals and objectives that are interdisciplinary rather than multidisciplinary should be achieved by encouraging thoughtful discussion of the “big ticket items” that are problematic in the eyes of the resident.

MYTH No. 8. Fall risk assessments are completed upon admission, with interventions devised by the nursing staff.
Fall risk assessment is a complex, ongoing analysis of the resident’s functional abilities that should be completed as an independent assessment each time a health provider has an encounter with a resident.
Upon admission, a fall assessment is performed; however, it should be expected that residents’ improvement in transfers or ambulation might potentially increase the risk of falls as their confidence increases with the use of rehabilitative therapies. CNAs should be informed of which of their assigned residents are receiving diuretics (water pills) for the treatment of congestive heart failure or hypertension in order for them to plan more frequent toileting activities.

Physical and occupational therapy assessments of fall risk should be incorporated into nursing interventions to provide meaningful measures to reduce falls.

Fall assessments used for residents in short-term rehabilitation units may not be applicable for residents in long term care units and should be tailored to meet the needs of the type of resident being cared for within the specific area of the facility.

MYTH No. 9. Nurses are used to administering medications and require little support and oversight during a medication pass.
One of the most important functions of a long term care facility is the administration of medications; however, little support is provided to the nursing staff in terms of understanding new medications, the identification of adverse medication effects, or the updated information about medication administration. The consultant pharmacist should be contractually obligated to observe a medication administration pass with a different nurse each month in order to be a resource, answer questions, and allow the nurse to become accustomed to being observed during the administration of medications.

During the process, the pharmacist should observe whether or not it is possible for a nurse to administer all of the medications to the residents within the accepted two-hour time frame. Suggestions should be offered to streamline medications, change the administration times of some medications, and offer suggestions to the physician to discontinue certain drugs, particularly those that have been prescribed for a prolonged period of time that may have little affect on the resident’s current status.

The medical director should also observe a medication pass several times a year in order to get a sense of the types and amounts of drugs that are being prescribed and to report this information to the attending physicians regarding the discontinuation of potentially duplicative or unnecessary agents.

MYTH No. 10. Teaching of residents and their families is best accomplished on the day of discharge in order to keep the information fresh and relevant. The visiting nurse can do further follow-up.
The process of education should begin on the day of admission by assessing what the resident and his or her family understand about the disease processes, medications, treatments, signs and symptoms, and emergency interventions. The educational needs of the resident should be discussed during the care conference.

Not all staff members are able to teach, however, and it may be necessary to identify specific nurses who have demonstrated skills in patient education.

Facilities should access written teaching resources, pamphlets, insulin starter kits, community support groups, and related materials to enhance staff knowledge to pass on to the resident and family.
There may be a gap of several days between the time the resident leaves the facility and the time the home health nurse begins care; therefore, the resident should have as much educational support as possible prior to discharge. If treatments or devices are to be used, staff should demonstrate their application and ensure that the resident or responsible party performs a return demonstration.

Ilene Warner-Maron, RN, PhD, is assistant professor, health services director, Interdisciplinary Health Services, at Saint Joseph’s University in Philadelphia. She can be reached at (610) 660-1586 or