Hi, I recently got offered a job at a SNF. I wanna take it but I'm nervous, I've never worked at an SNF. I hear negatives thing about working in SNFS, I dont wanna lose my license if I make a mistake. Can anyone tell me what a typical day in a nursing home is like? I was offered a 3-11pm shift.

Working at a SNF can be stressful due to the workload. The 3 to 11pm shift tends to be the busiest since this is when all the new admissions arrive.

However, the fears of losing your license are enormously overblown. The vast majority of licensure revocation occurs due to theft, drug diversion, impaired practice, or failing to satisfactorily complete mandatory impaired nurse programs.

In addition, few nurses lose their licensure over mistakes made at SNFs. I read the disciplinary action pages published by the BON in the state where I work, and the majority of nurses who lost their licensure were employed at hospitals.

In addition, I once worked in the SNF setting. The following content is a copy/paste of an old post I made years ago regarding how I organized my shifts.

I am an extremely task-oriented person, so when I used to work in SNF rehab, I always wrote my tasks on a to-do list and crossed them off as I completed them. After all, rehab/SNF nursing entails a huge workload of tasks that must be completed.

I worked on a rehab unit at a large rehab/SNF several years ago and here is how I used to organize for the day. I worked 16 hour weekend double shifts from 6am to 10pm.

I normally had about 15 patients to care for. At the beginning of the shift I would look through the MARs and TARs and, as I went, I jotted down the tasks that needed to be done in my notebook. My to-do list in my notebook was how I organized my shift, and as a result, I wouldn't forget to do anything.

Here is how an old notebook page from 2007 appeared (names have been changed due to HIPAA):

9-23-2007

DIABETICS, FINGER STICKS: Agnes (BID), Norma (AC & HS), Bill (AC & HS), Pauline (AC & HS), Rex (BID), Jack (BID), Ethel (AC & HS), Marjorie (0600, 1200, 1800, 2400)

NEBULIZERS: Marjorie, Ethel, Bill, Jack, Pauline

DRESSING CHANGES: Pauline, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Pauline (Vancomycin), Agnes (Flagyl), Rex (ProcAlamine)

COUMADIN: Agnes, Rose, John, Lucille

INJECTIONS: Agnes (lovenox), Lillian (arixtra), Rex (heparin), Bill (70/30 insulin), Ethel (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Pauline (wound infection), Rose (UTI), Rex (pneumonia),

1200, 1300, 1400 meds: Marjorie, Lillian, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura, Louise

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Norma's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

Welcome to LTC!!! A mod might want to move your post to the Geriatric forum.

Anyone can "lose their license." Being in LTC for the last 20+ years, I haven't seen it due to being a nurse in LTC but more for the nurses actions like stealing/ diverting drugs.

3-11 is a busy shift. The bulk of the admits occur on 3-11 shift, labs need followed up on and there are generally less staff and less support staff in the building.

My routine as a staff nurse:

2:45 arrive at work and get myself ready...pens, census sheet etc

3pm-3:30...make assignments, report, quick walking rounds and set up my cart, take off orders and look at any labs back

4pm-5:30...med pass

5:30-6:15...assist with dinner, monitor meal pass etc.

if able, take a lunch after residents have dinner, charting, follow up on order/ labs start treatments

7:30 start pm med pass and do treatments

10pm...finish med pass, more charting

11pm.....report

We generally try to have a charge nurse that will work on any admits, md orders and labs......that is a huge help. If not, it is all sqweezed in the above schedule.

if they don't have a census or cheat sheet, make your own.

I list the res room #, name, Md, full or no code, an area for quick notes and then a spot for IV/ accu checks. You might want to include their top diagnosis until you get to know your residents.

Moved to LTC forum

I would suggest doing your research about any LTC you are considering applying for. LTC's range from terrible to awesome, with everything in between. Sometimes different units of the same LTC have entirely different personalities.

Getting organized is key, but don't expect to figure out what works for you on your first day on the floor. Watch for co-workers who provide quality care and manage to get things done in a reasonable time frame. Ask them for suggestions, as you figure out the best way for you to be organized. I had a really tough time not being discouraged when I was a new nurse in LTC - but the experience I gained has proved invaluable in my nursing career.

LTC is hard work, but can be a great experience too. Prioritization, delegation, documentation, time management and lots of skills (wounds, IVs, lab draws etc) can be acquired in LTC.

2nd shift was actually my favorite shift:)

However, the fears of losing your license are enormously overblown. The vast majority of licensure revocation occurs due to theft, drug diversion, impaired practice, or failing to satisfactorily complete mandatory impaired nurse programs.

I agree. I know multiple nurses who have been found responsible by the board of nursing for patient deaths who still have their license and are still practicing (Which is not to say I agree with the board. In at least one of those cases I know for absolute certain that the nurse would have been me if I'd been assigned to that hall - I think it was a systemic problem that was unavoidable given the systems in place at the time). I know a nurse who hit a resident who apparently still has her license.

They're not going to take your license because you went outside the two hour window delivering meds to 35 residents or some other problem associated with SNF workload, or none of us would have licenses! It generally takes serious willful wrongdoing.

I agree. I know multiple nurses who have been found responsible by the board of nursing for patient deaths who still have their license and are still practicing (Which is not to say I agree with the board. In at least one of those cases I know for absolute certain that the nurse would have been me if I'd been assigned to that hall - I think it was a systemic problem that was unavoidable given the systems in place at the time). I know a nurse who hit a resident who apparently still has her license.

They're not going to take your license because you went outside the two hour window delivering meds to 35 residents or some other problem associated with SNF workload, or none of us would have licenses! It generally takes serious willful wrongdoing.

Thank you for writing this.

My true SNF experience is very little. I have worked in other types of LTCs: Assisted living Dementia unit as well as Psych.

As others have said, it's not likely you will lose your license because you work there.

The biggest challenges I think, are the high pt loads and trying to do the right thing when the system isn't always set up for you to be able to.

In the places I enjoyed working, I was busy, but I still was able to get things done that needed to be done.

in the places I didn't enjoy, there was too much work to be done and I noticed my coworkers were falsifying documentation or just not doing certain things-because there wasn't enough time.

I worked 3-11 quite a bit. The pros of that shift are that it starts off busy, but usually winds down to a quieter pace after the 1st or 2nd med pass.

One good thing about LTC pts is that you get to know the pts and their meds/treatments/needs so that, with time, you become faster at completing tasks.

A note on cheat sheets- TheCommuter posted great tips on what you may want to include. I personally preferred to use a census list rather than a task list. Depending on how mobile your residents are (aka how likely they are to be in their rooms during your shift) either go alphabetically or possibly by room#.

Your basic template should be name, room #, code status. Maybe add major notes to assist your med pass and treatments as you get to know them (crush meds, resident will only take meds in 3.75 cups of strawberry yogurt, dementia resident will only take meds if reminded she is taking a vitamin for eye health...stuff like that). After that i would list med, FS, and TX times, and any needed vitals (often BP and HR with beta blockers).

So for example: 101A John Smith DNR. 1600FS, 2100FS.

101B Jungle Joe Full Code. 1600 BP HR, 1700FS, 1900tx, 2100FS TX. Crush in pudding.

As to start each round going from one end of the unit to the other or however you go, you find the name on the list as you go, see if anything is needed at that time. If not, place a check by their name to indicate you saw them that round (so each person will have the same #of checks at the end of the shift-should be about 4). If they are due for something cross it off as you do it.

For FS and vitals my facility recorded these in the MAR and also a different binder so i would write the values on my the MAR and my cheat sheet as i did them to transcribe later.

If you keep anything with pt names from shift to shift remember to be HIPAA compliant- best to store them in the med room somewhere.

As others said, you aren't going to lose your license unless you are doing something seriously dishonest or negligent. TBH, you'll make a lot of mistakes and so will everyone else, but mostly it'll be missing giving someone a Senna or something like that. Sometimes it'll be a bit more serious (recently someone put on a fentanyl patch and forgot to take the old one off) and even then other than starting a report, nothing will really come of it. Of course you want to be careful, but you don't really need to be terrified, at least not for your license's sake.

I started out this shift. For me I should have had a TMA or another nurse on the floor with me but usually didn't. So a lot of my days looked like this with 20 or so patients on my floor, plus covering some things on another floor if it only had a TMA:

Get there at 2:15 (earliest I could show up)

Gather things together, check to see what labs, appointments, admissions, etc I needed to worry about

Get report and count narcs

Start med pass (never got the hang of getting it done on time)

Sometimes go downstairs to cover insulins and whatever else the TMAs aren't allowed to do

Get on the phone to order STAT meds that weren't ordered or ask for labs that were never received, get new coumadin orders while shoving some food in my mouth while on hold

Start HS med pass

Get that done late too

Again cover insulins

Do as many treatments as I could- fortunately the bulk of them were scheduled for day shift, so it's mostly nystatin powders and things like that. Try to finish admissions left from days or that came on during the evening.

Restock the cart

10:30 Give report and count, probably burst into tears in the process.

Finish up, leave at midnight or so if I'm lucky after I finish things up.

I've since switched to nights and it's quite a bit calmer. Never did get the hang of getting those massive med passes done on time. I still cover an evening shift once in a while and it's better staffed now but still- no thanks. A lot of people do like it though. Good news is less management around than on day shift, bad news is less management around than on day shift. At my facility for whatever reason the evening staff tend to be pretty unreliable, so I was often stuck by myself when I shouldn't have been, worked with useless aides, etc and I much prefer my night coworkers. That's probably facility specific though.

I'm currently working 2nd shift in LTC. My evenings look something like this:

- arrive at 2:45 PM.

- get report - if I haven't worked with the residents in that hall before, I always ask the off going nurse how they take their meds & write "w" (for whole) or "c" (for crushed) next to their name so I will know.

- check MAR to make sure all meds on day shift have been given (so they don't roll over onto my shift).

- do the narc count CAREFULLY (seriously, never rush this - always make sure the previous RN/LPN has signed off where he/she needs to and everything is accounted for).

- stock med cart, if needed.

- start med pass around 3:15-3:30 PM for 4 PM meds. It's usually a light med pass but I have to finish it by 5 PM bc that's when residents leave the unit for dinner.

- once I've finished the 4 PM meds, I will look to see if there's any orders that need to be noted, transcribed or faxed.

- also check to see who needs showers (so I can let the CNAs know ASAP), skin assessments (so I can do those as I pass meds).

- hand out meal trays when the dining cart arrives & feed anybody that needs to be fed.

- depending on the unit, I may have 7 PM, 8 PM, 9 PM, and 10 PM med passes. If that's the case, I'll usually start at 6:15-6:30 PM. If I'm lucky, I'll finish meds around 10 PM, sometimes later.

- do treatments after I've finished my med pass.

- give report at 11, do the narc count & sign off on it.

- head over to the charting room. Do Medicare charting, write up the skin assessments, write progress notes. Note any new orders or important conversations for family members, etc. (I carry a separate notepad during shift do I can take note of these things as I pass meds and do treatments. I write the time down so that charting will be easier later on.)

- leave by midnight, on a good night.

The work load is humongous. You will get faster with meds when you figure out how everybody on your unit likes to take them. The nurse training me has always said: be very careful when passing narcs, but with anything else, relax a little. Most of "everything else" is vitamins, BP meds, melatonin, Metamucil, Miralax, etc. Of course, no one wants to make a med error but it will inevitably happen when you're passing that many meds.

With treatments, you'll usually have to improvise - don't feel bad, everyone else does, too. You're doing the very best that you can with limited resources. Just use your common sense and nursing judgment and you should be okay.

The tougher nights are when you have an emergency (fall, someone becomes acutely ill and needs to be sent out, or if someone passes away on your shift) or when you get a new admission (you really only have to worry about that happening early in the shift). In that case, you do the best you can and if you're late with meds, so be it. Anyone else would be, too.