Geriatric Nursing
Volume 28, Issue 1 , Pages 27-30, January 2007

Assisted Living Nursing Practice: Admission Assessment

Article Outline

Admission assessment, generally conducted by a registered nurse, is autonomous, without opportunity for dialogue with colleagues and other health care professionals and bounded by the nurse’s knowledge and skills, state regulations, facility practices, and marketing. The fact that some states permit admission and retention of nursing home level-of-care residents and provision of end-of-life care means that the assessment has to be able to predict the resident’s likely trajectory of well-being as well as chronic illness exacerbation. The nurse must have a clear perspective on staff competencies and judge whether additional education or training will be necessary. This article reviews assessment standards of practice as put forth by the American Assisted Living Nurses Association as part of its application for recognition of assisted living nursing as specialty nursing practice by the American Nurses Association. The role of the Licensed Practical Nurse/Licensed Vocational Nurse in resident assessment is also discussed.

 

Being an assisted living nurse means autonomous decision making and managing care and systems in relative isolation from collegial and interdisciplinary discourse. The preadmission and admission assessments call on being able to predict the resident’s likely trajectory of well-being and chronic illness management needs and aging in place.

A brief overview of residents in assisted living (AL) is instructive in setting the context of assessment. Most residents are aged over 65 years and need some assistance with activities of daily living (ADL) and instrumental ADL.1, 2, 3, 4 In comparison to nursing home residents, AL residents are more likely to require assistance with bathing and dressing, less likely to need help with toileting and locomotion, and unlikely to need help with transfer and eating.1, 4 On average, residents need assistance with 2.8 ADLs. As many as three-fourths of residents need and receive some kind of assistance with medication management, from assistance to full administration.1 Residents experience functional decline over time that is similar to that found among nursing home residents.5, 6

Although almost half of all AL residents have no cognitive or physical impairments, some are in good physical health but suffer significant cognitive impairment, some are functionally impaired because of chronic illness, and some are dually impaired.7 Nurses conducting assessment have to be aware of special state regulations for dementia care in AL (e.g., evacuation plan, staff education, and a written plan to minimize the use of psychotropic medications). Inasmuch as most states permit hospice services in assisted living, end-of-life care also has to be part of the projection of future care. Given the expansiveness of hospice services to include those suffering with end-stage dementia, it is altogether likely that some of the approximately 68%–81% of residents with a dementia illness will remain in the AL residence (ALR) to the end of their lives.7

Constrained by state regulations that specify the range of allowable services—as well as retention and discharge criteria—and what the ALR chooses to provide, the nurse conducting the preadmission assessment is carrying out a professional responsibility bounded by knowledge, skill, ethics, and marketing. The fact that some states permit ALRs to admit and care for nursing home–eligible individuals can be terribly confusing to an older adult (and family or significant other) contemplating relocation from one state to another, for a variety of reasons. Different levels of assisted living settings further confuse the prospective resident and, in a sense, speak to the mixed image of what assisted living is. Hence, the admission assessment has elements of selling/marketing the ALR.

Admission determinations, dependent in large measure on the nurse’s assessment, are shaped by the nurse’s thorough understanding of the care capabilities of the assisted living community. Although a medical condition may be technically “allowed” according to regulation, the nurse must have a very clear perspective on staff competencies and if additional education and training will be necessary to meet the needs of incoming residents. What is the extent of knowledge among unlicensed assistive personnel with regard to psychological medication effect? The prospective resident’s compatibility with the other residents must be considered because, after all, the residence is supposed to be “like home.”

The ongoing provision of social- and health-related services and of episodic acute care and monitoring with skilled nursing (oversight) typifies the AL environment. Not sick or unstable or fragile enough to require the skilled nursing and medical oversight of nursing home care, the older adult in AL should receive the amount and type of care needed to optimize function and quality of life. Therefore, each prospective resident requires a thorough holistic assessment so that the admission decision reflects the older adult’s personal goals for his or her well-being and quality of life. What data constitute an assessment? What competencies are necessary? The principles of assisted living nursing—a unique blend of gerontological and administrative nursing—guide the assessment process.

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Standards of Practice: Assessment 

Standards direct practice, are a framework for performance evaluation, and must reflect basic competencies. The suggested template for standards of practice, promulgated by the American Nurses Association (ANA), are as follows: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.8 Each standard must include measurable indicators or criteria. The American Assisted Living Nursing Association (AALNA), in preparation for recognition of assisted living nursing as a specialty nursing practice wrote the Scope and Standards of Assisted Living Nursing Practice for Registered Nurses. Based on the ANA guidelines, the AALNA standards of practice are “an authoritative statement” of responsibilities and accountability of assisted living nursing.

The rationale for an assessment standard of practice rests on the obligation to construct, evaluate, and modify as needed a comprehensive plan of care that reflects the resident’s preferences, wishes, and needs to reach and maintain the individual’s desired quality of life. The assessment standard is straightforward; the nurse must use standardized instruments and techniques to collect information. In a combined role that can include residence administrator, wellness coordinator, and clinical nurse, the AL nurse should provide input regarding the adequacy of the data collection system addressing health care delivery for AL residents. The challenge for the nurse is knowing about the reliability and accuracy of various assessment instruments and is particularly so with regard to a resident’s decision-making capacity and ability to self-administer medications.

The “measurement criteria” that are an essential component of the standard of practice indicate the information needed to make an informed assessment and the associated activities. Some states have a prescribed admission assessment tool, but that should not preclude using other valid and reliable assessment tools and instruments to further understanding of a prospective or new resident’s needs and wishes (see Resources at the end of this article).

The AALNA assessment practice standard identifies the domains that assessment should include, at a minimum. The italicized statement suggests that the basic “shopping list” information is not sufficient; there is more to know about this person who might be coming to live in the ALR.

•Functionality (ADLs): self-care ability, assistive and supportive needs (e.g., cueing, supervising, reminding). Determine what capabilities the resident would like to retain and what capabilities/tasks they would not mind relinquishing (e.g., medication self-administration).

•Instrumental activities: make no assumptions about interest or willingness of the older adult to manage shopping, banking, light housecleaning. Determine, for example, whether anyone in the resident’s constellation has assumed financial decision making.

•Medication management: self-administration and the level of assistance or supervision needed. Eyedrop self-administration (e.g., for glaucoma) is radically different from oral medication administration; how will this ability be ascertained?

•Safety needs: this includes history of and likelihood of falls, elopement, driving a vehicle, abuse, and mistreatment. Has a history of falls become a barrier to the older adult’s interest or willingness to go on trips? Ask how frightened they are of falling again.

•Comprehensive history: includes prior medical and surgical history, current problems, systems review (including oral cavity, sleep pattern, pain management, etc.), current medications, allergies, coping patterns, health promotion practices. Ask residents who or what has assisted them when dealing with major issues or crises in the past.

•Lifestyle: past, present, desired. Ask residents what they regret never having done; what they would like to do next.

•Perceptions and beliefs: what is the older adult’s perceptions of his or her current health status and desired health status? Ask residents what stands in the way of their achieving their desired health status. (This is an important question; it has to be addressed in the light of what the ALR can do to support this quest and goal. In a sense, this is a marketing issue.)

•Spirituality and cultural beliefs and interests.

•Social network: past, present, desired. Ask residents what kind of person do they feel most comfortable with? Least comfortable?

The admission assessment should also address health care decision making: who were or are the decision makers? This is not simply an issue regarding advance directives (such as Health Care Proxy and Living Will) but the likelihood or necessity for a “negotiated risk” arrangement on admission or at some future time. Residence policy needs to address, also, confidentiality of the assessment data and the informants.

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Licensed Practical/Vocational Nurses (LPN/LVN) and the Admission Assessment 

The precise number of LPN/LVNs in assisted living practice is unknown; it is estimated that 65% of ALRs are staffed in whole or in part by LPN/LVNs working under the supervision of RNs (or advanced practice nurses [APN]). The Scope of Practice for LPN/LVNs in Assisted Living, an AALNA document that specifically recognizes LPN/LVN competencies and status as AL nurses, includes planning and supervising care for residents with stable conditions, and basic physical, mental and psychosocial assessment. LPN/LVN activities with regard to preadmission assessment is likely minimal in that many states require an RN or physician assessment recommending such admission. However, postadmission assessment is more than likely an LPN activity, delegated by a supervising RN/APN who is off-site but an official consultant to the residence.

Although the RN is responsible for analysis of the data, the LPN/LVN has a critical role—and responsibility—in the accurate collection and communication of assessment data. Given the likelihood that a typical ALR is managed by an LPN/LVN, these nurses would have intensive knowledge of residents’ needs and interests. Hence, LPN/LVN input into a prospective resident’s probable “fit” with the current residents and the ability of the ALR to provide needed care and services (currently and in the future) should be part of the admission discussion and decision.

The Marketing Aspect of the Preadmission Assessment 

How many AL nurses realize that the preadmission assessment is part of the sales process or marketing activity? Many prospective residents who would formerly have felt that they had no option other than to live in a nursing home, now consider AL a viable option. Indeed, these residents, whether private pay or Medicaid, are the subject of intense marketing and competition among residences. During the assessment and interview, the nurse can, perhaps, refute some of the myths of aging: although there may be increasing frailty, there is not necessarily senescence and rampant impairment of physical or cognitive function; pain and depression are not a normal accompaniment of aging. As needs are identified related to health status and self-care limitations (current and projected), the nurse is ideally—and ethically—positioned to explain how the ALR can (and cannot) meet likely needs. The admission assessment is an opportunity to identify reversible conditions and even to do some preventive health teaching with the older adult who might remain in the community for some time before coming to live in the ALR. This kind of compassionate and caring action by the nurse during the assessment affords the resident a glimpse of the quality of care that can be anticipated once the resident joins the assisted living community. Thus, an unintended consequence of assessment is that the nurse “cinches” the placement.

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References 

  1. Golant S. Do impaired older persons with health care needs occupy US assisted living facilities: An analysis of six national studies. J Gerontol B Psych Sci. 2004;59B:S68–S79
  2. Burdick D, Rosenblatt A, Samus QM, et al. Predictors of functional impairment in residents of assisted living facilities: The Maryland Assisted Living Study. J Gerontol A Biol Sci Med Sci. 2005;60:258–264
  3. Zimmerman S, Eckert JK, Gruber-Baldini AL, et al. How good is assisted living? (Findings and implications from an outcomes study). J Gerontol B Psych Soc Sci. 2005;60:S195–S204
  4. Morgan LA, Gruber-Baldini AL, Magaziner J. Resident characteristics. In: Zimmerman ,  Sloan S,  Eckert PD editor. JK Assisted living (Needs, practices, and policies in residential care for the elderly). Baltimore: John Hopkins University Press; 2001;
  5. Fonda S, Clipp E, Maddox G. Patterns in functioning among residents of an affordable assisted living housing facility. Gerontol. 2002;42:178–187
  6. Frytak J, Kane RA, Finch MD, et al. Outcome trajectories for assisted living and nursing facility residents in Oregon. Health Serv Res. 2001;36:91–111
  7. Gruber-Baldini AL, Boustani M, Sloane P, et al. Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management. JAGS. 2004;52:1610–1617
  8. American Nurses Association. (nursesbooks.org Nursing: scope and standards of practice. Washington, DC: American Nurse’s Association; 2004;

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Resources 

  1. In:  Mezey M,  Fulmer T,  Abraham I editor. Geriatric Nursing Protocols for Best Practice. 2nd ed.. New York: Springer Publishing Company; 2003;(Note: 3rd edition will be available in 2007.)
  2. GeroNurseOnline: Current best practices information; search the site by patient clinical signs and symptoms, specific geriatric topics, or specialty nursing practice areas. Organized into three levels: Need Help Stat, Want to Know More, and Topic Resources. www.geronurseonline.org
  3. In:  Gallo JJ,  Bogner HR,  Fulmer T, et al. editor. Handbook of geriatric assessment. 4th ed.. Boston: Jones and Bartlett; 2006;
  4. Maryland Office of Health Care Quality. Final assisted living assessment tool: health care practitioner physical assessment and assisted living manager’s assessment. Available at www.dhmh.state.md.us/ohcq/alforms/alforms/htm. Catonsville, MD: Department of Health and Mental Hygiene.
  5. Try This: A series of assessment tools where each issue focuses on a topic specific to the older adult population. Available at www.hartfordign.org/resources/education/tryThis.htm.
  6. Zembrzuski CD. (www.DelmarNursing.com) Assessment of the older adult. Albany, NY: Delmar Thompson Learning; 2001;

Ethel Mitty, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, Consultant in LTC at John A. Hartford Institute for Geriatric Nursing, New York University.

Sandi Flores, RN, C, is executive director, American Assisted Living Nurses Association and education director of Community Education LLC (www.communityed.com).

PII: S0197-4572(06)00361-2

doi:10.1016/j.gerinurse.2006.11.013

Geriatric Nursing
Volume 28, Issue 1 , Pages 27-30, January 2007

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