Nursing

Private Duty Nursing Expectations

As a nurse, you are carrying out very important instructions. The instructions were given to you by a physician and treating them seriously helps to make sure that your patients get the care they need. It also helps to protect you (and All Metro) from liability. Every time you visit a patient, take what you are supposed to do there seriously and document the full extent of your activities.

The New York State Office of Medicaid Inspector General ("OMIG") is charged by statute to improve and preserve the integrity of the Medicaid program by conducting various reviews of provider billing patterns and practices. As part of a recent non-targeted prepayment review of the agency's private duty nursing claims, several inconsistencies between clinical practice and the New York State Private Duty Nurse Provider Manual were noted. A sample of the findings from several records, with patient information redacted, is presented below to ensure you understand areas where improvement is needed going forward.

Vital signs were ordered every shift, and as needed. There are no blood pressure readings recorded in the clinical notes. Medication administration record is incomplete. Numerous PRN medications were administered without specifics to time, or effectiveness. MD orders indicate RN supervision is every two months, and as needed. Narrative portion of the clinical note should have timed documentation every one to two hours.
Albuterol use and effectiveness is not documented in the nursing progress notes. The medication administration record is transcribed as using for wheeze/congestion, however physician orders state use is for wheezing. Allegra use is almost daily, however, there is no documentation of what allergy symptoms are being treated. Focus improvement on documentation and effectiveness of all PRN medications.
PRN medication administration sheet indicates Bacitracin is used twice a day, and Aquaphor Cream daily and for months at a time. The use is indicated for treating redness and irritation, at two different sites. Administration is documented as being given the same time(s) every day and is documented as being effective. If this is the case, then the conditions being treated, and the need for long term use should to be evaluated by the supervising RN.
Our findings showed: Gas-x is on the MAR as a tablet however the physician order is for suspension. Miralax is on the MAR with divided doses to be administered one hour apart yet the physician order is for administration every half hour. Dulcolax suppository is transcribed on the Medication administration record as PRN every five days. The MD order states for administration every other day; not as needed. Duoneb is on the PRN medication sheet. There is a standing order for this medication; there is no PRN order. There are changes made improperly in progress notes, and on the MAR (written over, crossed out). Any corrections should be made by making a thin line through the entry (making sure that the inaccurate information is still legible) state error, (in the margin or above the note) and initial. Change of date needs to be reflected in the clinical note on overnight shifts.
The medication administration record (December 2018) has an order transcribed for oxygen, however it is not in the physician orders (states oxygen precautions). A & D ointment is on the Medication administration record to administer twice a day; however, it is not on the orders for certification period 11/25/18-1/23/19. It is indicated as a new order in the following certification period but is written for once a day as needed.
Progress note on 1/04/19 records a seizure lasting 8 minutes in which the vagus nerve stimulator magnet was used. The MD order states to give Diastat for a seizure lasting more than five minutes. There is no order (on the provided MD orders) for the vagus nerve stimulator. The progress note does not describe any response to use of the Diastat, or the specifics of client’s recovery following the seizure. Observed were a six-minute seizure on 1/7/19, and another on 1/15/19 with no documentation of duration. There is no indication of any medication intervention used for either of these episodes, and no documentation of seizure activity in the narrative nursing note. A ten-minute seizure is documented on 12/19/18 “getting on the bus.” There is no further documentation regarding the characteristics of the seizure, or of the client’s recovery phase.

There are handwritten medications on the Plan of Care list, and changes made to the Tylenol order. These additions and changes should be reviewed and initialed by the covering physician. February medication administration record was corrected improperly (written over). Item should have a single line through, error indicated, and initialed.

If you have any questions regarding expectations, please contact the Director of Clinical Services for your branch immediately. You may also use the form below to contact our VP - Patient Services. Thank you!

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Private Duty Nursing Expectations

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