Serenity Care Calamity

Situation 1: Day 1 at Serenity Care Center

You are a newly hired nurse practitioner at Serenity Care Center, a skilled nursing/rehabilitation facility. You’ve already completed your HR paperwork and onboarding and it’s time to start working with patients. You stop by the nurses’ station and see that one of your assigned patients is Sven.

Zareen stands behind the nurses’ station, which has computer and files on it. A wheelchair, plants, and furniture are nearby.

What do you want to do now?

Look at Sven’s Care Plan.

Sven’s room has a lockable closet, a lockable set of drawers, a whiteboard, a green chair, and windows with a curtain. Sven is in a hospital bed with the head raised. A whiteboard of info is on the wall. His chart hangs below the windows.

To Escape

Read Serenity Care’s Skin Breakdown Policy (Word).

What should be Sven’s care plan? Select two items based on what you found.

Apply elbow protectors to intact skin over elbows.

Apply heel protectors to bilateral feet.

Check heels daily.

Encourage Sven to report pain over bony prominences.

Encourage Sven to ambulate outside the room at least BID.

Encourage Sven to use lotion to prevent skin cracks.

Keep feet elevated while immobile.

Only perform skin assessment and inspection q shift. Pay attention to heels. No other intervention is required.

Post a turning schedule.

Correct

Hint: Be sure to look through Sven’s room for the Braden Scale and care plan.

Situation 2: Day 3

Two days later, you follow up on Sven’s care plan. Alas, Sven has no heel protectors, and his feet are not elevated! In fact, you find no notes in his chart about the intervention to apply heel protectors and keep the feet elevated. You realize you need to seek out Serenity’s wound care nurse to find out what the facility’s policy and procedure is so you can make sure Sven is receiving proper care.

Nurses’ Station

You head to the nurses’ station.

Breakroom

You know Luke is around today, so you go to the breakroom next.

Room 501

To Escape

Hint: Did you talk with Zareen, Quinn, and Marc?

Room 532

White man with short spiky blonde hair wearing a pink button-down shirt and a black and grey striped tie — Luke

Hi, yes, I’m Luke, but unfortunately, I’m just the temporary replacement for Louie, and I’m not a specialist in wound care. I’m just an LPN who took a seminar last month, so I had the most recent education when Louie had to go on leave. I mean, I want to become a Certified Wound Care Associate, but I don’t have it yet.

Situation 3: Day 18

It’s been a little more than two weeks on the new job, and you feel like you’re settling in. You can see some places where the procedures could use some work, but you’re understanding them and are getting a good feel for how things work at Serenity. You are getting into a good rhythm with the team.

Today, when you greet Sven, you think he looks a little gaunt. You ask him how he’s feeling.

An old man with short grey hair wearing a hospital gown — Sven

I’ve been better. I’ve been having a hard time eating here. Perhaps it would be better if I could get up and eat with others in the dining room or play some cribbage?

You check the weight record (PDF) in Sven’s chart. Now you need to find the Weight Assessment and Intervention Policy.

Where do you find the policy?

You know by now that policies are often found in various places, but that a good place to start is the breakroom filing cabinet.

The breakroom has a fridge, cabinets, microwave, coffeemaker, water dispenser, filing cabinet, bulletin board, first aid kit, lounge chairs.

So you ask Zareen at the nurses’ desk.

Black woman wearing a black and white headscarf and a stethoscope — Zareen

Oh, yes, the weight assessment policy is most likely in the breakroom cabinet. I’m not sure where Marc is right now, but I’ll page him to meet you in the breakroom with the key.

You return to the breakroom; about five minutes later, Marc arrives.

White man with short red hair wearing a janitor's uniform — Marc

Hi there, Zareen paged me about a key. How may I help?

He unlocks the cabinet for you. After about 10 minutes of riffling around, you find the Weight Assessment and Intervention Policy (Word). Marc waits for you to find it so he can lock the cabinet again when you are finished.

To Escape

Check Sven’s weight record.

What are the three most important steps to take now?

Check Sven’s vitals.

Communicate to Sven’s PCP in a timely manner.

Conduct a skin assessment.

Consult Sven’s care plan.

Make a note in Sven’s medical record.

Report to Shantal, the DON.

Talk with the nutritionist.

Correct

Check the Weight Assessment and Intervention Policy.

Report to Shantal

Shantal assesses Sven immediately upon being notified of his significant weight loss. She notes that Sven now has Stage III pressure injuries to both heels. In looking through the chart, she finds there is:

No record that Sven’s PCP was ever notified about the weight changes.
No documentation of the skin issue being monitored.
No documentation of the intervention of the heel protectors/heel elevation being initiated.

Shantal also points out an outstanding lab result that shows Sven has significant hyponatremia (low sodium level) that requires him to be sent to the hospital after contacting his PCP.

I would like to plan a meeting for you and the others involved in Sven’s care to discuss his current situation. Please let them know and keep your schedules open for us to all meet first thing tomorrow morning.

Feedback:

Shantal suggests you think about the following issues before the meeting:

Delegation and appropriate supervision
Documentation
Interprofessional communication
Policies & procedures
Staff responsibilities and chain of command

Summary

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