Nursing Home Supervisor challenges with WOUND CARE

[ShimmaShimma0304]

Hello everyone,

I'm in SERIOUS need of advice, please. I started a nursing home supervisor job in the summer of 2017 and, even though I've been a charge nurse in my 22+ year career, this supervisory role is new for me. I have a more laissez faire type management style and I'm working on becoming more respectable as a manager. I can only do so much, it feels like, though. I have a dual role in my job and I'm a wound care nurse at my facility as well.

The LPNs are supposed to do weekly skin assessments on their assigned group of residents and that doesn't always happen. Months ago, I let everyone know that corrective actions would start happening if they didn't do them and print them out for me to review... it didn't seem to matter. I still get 2 out of 3 or 3 out of 3 in a 5-week review period. So, for those who I notice only do their assessments sporadically, I've done corrective actions. One nurse has pushed me to do 2 on her within the last 4 months. She has a HORRIBLE attitude anyway... So, fine. NOW I'm having issues with the nurses not doing their dressing changes-- they sign them off to be done but don't actually change the dressings. I had to write up 4 people for this last week. All of them had excuses and said they "meant to do them but forgot" or "the computer changed the entry from an "N" for "not done" to" their initials accidentally. Do you believe that??? Insert *eye roll* here. So I'll have to keep a check on this very closely from now on. I can't believe they don't understand the seriousness of this neglect. Because that's exactly what it is... !!!

My main dilemma and why I'm posting for advice is in regards to my CNAs and the fact that I can't get them to consistently use heel protectors, float heels, turn people off their backs and use pillows (that's so BASIC!!!!) and I've even implemented the use of disposable foam wedges to turn our residents with actual wounds on their backsides OFF of their bottoms. I can't get them to use them consistently. Some units are good about it and some just like to keep them on the resident's chair, on the floor or lying beside them in the bed but not actually UNDER them where it's actually doing the person any GOOD.

There are 3 shifts and I'm only there for 10 hours a day, 4 days a week. I've asked for the help of unit managers and for other supervisors but they also have their own jobs that they are trying to juggle. The DON said that it's the LPNs responsibility, as well as the CNA's, to make sure the resident is being cared for properly. I understand that... but how the heck do I drive home the seriousness and that there are consequences to their not doing what they are supposed to do? I don't even think they would care if I wrote them up to the point where it was a final warning. I don't even think HR would let someone get fired over not using a foam wedge. But then it's MY responsibility. I'm just at a loss and need advice from someone who is maybe going through something like this or who has gone through this in the past. What have YOU done??? What works to make people 1) CARE and 2) do what you ask of them?????

I organize the inservices for the CNAs every month and even when the inservice isn't about pressure ulcers, I still mention this as being super important. YES, we have agency CNAs and LPNs as fill ins but they aren't always the problem. It's our own staff as well.

Thank you so much!

[ShimmaShimma0304]

They are doing false documentation- maybe have a chat about ramifications with the BON.

Also if the company won't let someone get fired over this stuff maybe a chat with the risk manager is in order. If a patient develops a pressure injury and goes septic or goes septic from dressing changes not being completed the company will have an even bigger problem...

YES! We discussed the falsification of documentation last week when each of the 4 nurses was written up over documenting that they did the dressing changes yet they weren't done. Again... they just apologized and said they forgot and they would do better, etc. One lady said that the computer changes her documentation from "not done" to her initials... isn't that fancy that the computer will do that???? (seriously? give me a break!) The DON was present when we had THAT lady in the office to discuss the corrective action. She makes NO sense whenever she's trying to "defend" her actions. I can't even keep up with her rambling.

But we did discuss the legal ramifications... and I told them all, "Forget the fact that we are in the window for the state survey to be happening... State could come in at any time... and if they want to go with me to do a treatment and I turn a resident over and their dressing is 5 days overdue from being changed..." Our facility has already gotten a deficiency over this very thing about a year or so ago when I wasn't working there... It will just have to be brought up in future inservices... Maybe I can get a legal nurse of some kind to come in and talk to them... Hmmmmmm... That's a thought. :) That would be awesome.

[ProperlySeasoned]

Sounds like there is a culture of pre charting. That needs to be addressed. I agree with the nurses that said they "forgot." That's the danger of charting something you have not done yet. Here's a question: Do the LPN's know how to do a propper dressing change? Do they have the supplies? Do they have enough time in the day to do so?

[djh123]

No suggestions really, but 'I feel your pain'. At my previous LTC/rehab job, I had 2 problems similar to yours. CNA's who wouldn't put someone's padded boots on, or wouldn't turn them, or didn't put barrier cream on a sensitive area - and/or in some cases, residents would refuse boots, or to be turned. And then yes, sometimes I'd follow a nurse or two who were supposed to have done so-and-so's wound on day shift but hadn't.

Akin to an Avon lady jokingly telling my ex one time that 'It ain't gonna do you no good in the bottle', wound care ain't gonna work if we don't DO it.

[Have Nurse, ADN, RN]

Someone might need to lose their job. Because clearly the "corrective action" is neither.

That's what I'm thinking, not to mention reporting the L.P.N.s to the Board for falsifying records which incidently, is illegal. Put some teeth in it.

[Caprica6]

It might be time for a surprise visit from your state ombudsman or health department...

[K+MgSO4, BSN]

Part of my management approach is to ensure that the staff have all the supplies to do their job. Do yours have dressing trollies, correct dressings and enough of them, sterile gloves in the correct size etc?

Do they need leg lifters to attach to the hoist to lift a leg for a heel dressing if the patient can't lie prone for the dressing?

[Crush]

Someone might need to lose their job. Because clearly the "corrective action" is neither.

Although I hate for someone to lose their job, in this case there has been corrective actions. The catch is the facilities policy of it goes away after a year and I imagine staff knows this. I am happy to read the OP does have their supervisors support though.

That's what I'm thinking, not to mention reporting the L.P.N.s to the Board for falsifying records which incidently, is illegal. Put some teeth in it.

I still think consistency is key here but I sure hope that this improves soon. Maybe it is time to rethink the timeline for those warnings to "reset".

I totally agree with you OP, "Where are these people's conscience?"

[cyc0sys]

I never heard of a Nursing Home Supervisor. It sounds to me like an administrative title so that might be part of your problem. Also, if you've never worked the floor in an LTC as nurse, I wouldn't expect a lot of respect or compliance. I've seen too many 'seasoned' hospital RNs walk into the LTC only to turn around and walk right back out because they don't understand the culture or worst, though it was going to be some cake walk.

I wouldn't go around threatening people's license unless you have enough evidence to bury them criminally and enough money to defend yourself in court. These are the people who know where all of 'the bodies are buried' (think thousands of pages of regulations that are broken everyday by facility) and probably aren't purposely doing wrong but have no recourse.

That being said, I've never seen an LTC properly staffed, budgeted and supplied unless it was private pay and didn't accept medicare or medicaid. Maybe you work in one of these magical mythical unicorn filled places, I don't know.

Remember, it's just as easy for anyone to call state or the ombudsman and report the facility for medical negligence.

I don't worry about those things myself. I understand the terms: turning state's evidence, immunity, witness for the prosecution, and defamation tort law.

Don't do anything your career can't handle.

[OldDude]

Are you the DON of this facility?

[Neats, BSN]

Being a manager is not all sit in office and play, being a good manager is hard. The hardest is follow through. It is easy to discuss what needs to be completed, to discuss a policy/regulation. What is hard is to go back and hold people accountable for what you have clearly instructed them to do. I was a traveling Licensed Nursing Home Administrator and Director of Nursing for over 20 years. What ever facility I went into I was a hard *** from the get go. No wriggle room for anyone and I worked long hours, mostly doing admin stuff and then on the floor making sure people were doing what they were suppose to be doing, reviewing documentation...once things became better I would let up. With that said it sounds like you need some mentoring.

Because you are established in this facility as the nurse who communicates and wants things done (you come from a good heart) but it appears you do not use your authority or you have the responsibility without the authority and now you need to take things away which is more difficult than being a hard *** but it can be done. I would have my days go something like this for at least one month:

If a shift starts at 0700 hrs I would get to the facility at 0530 hrs.

1. Do a round of the facility say good morning, is there any concerns... let this last only 20 mins-30 mins dependent on the facility size.

2. Review the 24 hour report (it may not be completed for night shift and this is OK on your rounds you have some what of an ideal of what is going on. Review for not greater than 20 mins.

3. Look at the schedule and see who is on, I would do the assignments for all nursing staff (again you know what is going on because you looked at 24 hour report and asked questions to NOC staff). Take the time for at least one hour for this task because this includes break times/wound/shower/meals/who will take the admits if any for the day...after the initial 2 times you have done this it will get easier and will not take as much time. When staff complained let them know that these issues have been discussed, no changes occurred that improved with the needed regulation (although you appreciated everyone's help) and now you have to take a different path in order to place us back into regulation. You should have each staff name with a check list on their tasks you need to keep. Or if you will each task should have a staff name who is responsible for the completion. Example

There are 4 tasks that need to be completed

3-1. Wound care dressing changes for XX patient need to be completed 1500 hrs (5 in AM and 3 in in afternoon all done before 4 PM. RN Jones is responsible for this today to let the unit nurses know they have dressing changes to do today. and will give you a list of what dressing changes occurred and what nurse was assigned the dressing change. So in short RN Jones is placed in charge with the wound care completion today, they will report to you about the wound care status. You have the chance to ask why it has not been completed, if they say I don't know then you must take RN Jones with you hunt down the nurse responsible for the actual wound care changes and ask if there are any problems. If so then the 3 of you can attempt to solve them.

3-2. BP need to be completed by 0800 hrs Sue Smith NA-C is responsible for seeing that all needed BP results are provided to licensed nurses. This one is easy all must be completed by specific time so the nurse can give medication if not done then write up the NA-C who was suppose to get it done unless an emergency.

3-3. Any Admitting completion is handed to Joe Flow RN who will provide you with the completed paper work 30 mins before end of shift. Again admission should be completed UPON ADMISSION this is part of patient safety and part of keeping you license as a nurse squeaky clean. You need to know what you have.

3-4. Shower's assigned Stephanie NA-C will be responsible for providing to each unit licensed staff member the names and completed shower check list that includes any concerns by 3 PM. Again if not completed then write up unless there is a good reason.

4. I would leave by 7 PM and I always came in a few times on NOC shift for the whole shift. Long days but effective and productive.

So once you have this what you do next is every 2 hours you go back and check on your designated nursing staff to see how they are doing with their task assignments and to see if any of the assignments have been completed. If they completed tasks them out on your list and go onto the next 2 hours and do the same. Is this micro managing yes and no. You have made people responsible for a portion of what needs to get completed ether in the form of them doing this themselves or to delegate this. Even the NA-C can do this. If it does not get completed go back to that assigned person and ask why it was not completed.

Since you are going back to these people you delegated tasks to every 2 hours after the second time they generally know they need to get it done. It is OK to say to them you know there are 8 showers today and it is 10 AM. A shower takes time and this needs to get done, I am expecting at least 4 showers within the next 2 hours when I come and ask you again. I am not trying to be mean just want us to be in regulation. Do not discuss anything else...just let them know I think you are resourceful and will report back and show me the documented showers that have been completed. When you talk to your assigned staff I would let them know I need you to write down the names of who you spoke to and what you delegated them to do and time you spoke to them.

If the work was not completed then I would go directly to that person WITH Sue, Joe, Stephanie, RN Jones to ask why it was not completed. If they do not have a great excuse i.e. we had a patient expire, this resident was running a fever, wound care was completed last NOC because the dressing came off...If no good excuse I would ask to speak to that employee who was suppose to do the task alone in private and write up a little discussion was made, give them a copy of the policy/regulation (I even give out F tag verbiage). Excuses are easy, people can rationalize anything. Keep in mind once you allow the excuses you will have no control over your environment. I am forever saying to employees make it work. This may mean your favorite person who you like to go to lunch with you will not be able to but you both get a lunch.

So basically your whole day is to be a babysitter. This works, you can do this in a dignified manner, in a respectful manner. It sends a clear message that work is work and we must comply with regulations and policies. You will have complaints, you will have people put their resignation in, you may in the long run have a wonderful staff (you more than likely already do) that now know a clear working environment that is in compliance, that can handle hiccups without too much interference, and that is providing great care. The residents will be happier and so will the staff in the long run.

Lastly I would have copies of common policies, F Tags, regulations ion my desk so when I do speak to an employee I always say at the end I look forward to improving our facility with you, here is the regulation, policy F Tag that shows how we must be in compliance and why we are suppose to do things this way. I look forward to you teaching this to to others.

Hope this helps you to be a better manager.

[nursej22, MSN, RN]

I agree with doing a deeper assessment of the why the dressings aren't getting done, getting the past "I forgot, I'll do better." Is it time, supplies, knowledge, prioritization?

Have you tried to schedule sessions where you and the LPN do the dressings together? Maybe you establish a routine that you will watch x number of dressings each week. They have to do it if you are there right? And this would give you a good idea of work flow. And you heap on lots of praise when a job is done well. Remember to praise in public, and correct in private. And use the "onion sandwich" delivery. Say something positive, say what could be better, and then follow with a positive. "Jane, I see that you have a great rapport with the CNAs. I have noticed that Mrs. X does not have her wedge in place. Please encourage your team to use them every time. I know that we all want to avoid pressure ulcers."

How about some motivational interviewing? Do staff feel that dressings are important? Do they understand the benefits, and risks when they aren't done? To the patient I mean, not just the threat of a warning. Do you have any success stories about healing a bad wound? At my first job we had a person come in the a stage 4, almost completely closed with good turning and wet to dry dressings. The staff was so proud of what they were able to achieve.

Obviously the write up approach is not working. I personally would come at this from a team approach and show the staff that you value them and believe that they can deliver excellent care.

[Davey Do]

I truly appreciate your plight and endeavors to assure quality care is provided to those you serve, Marie0304!

This thread could be interpreted as a data gathering/brainstorming process in dealing with the problem of skin and wound care goals not being met. There was mention of sanctions toward those not fulfilling their duties. This is a viable option and can change a culture only if the reasons for the sanction is made clear: Resident neglect is a form of abuse. Sanctions are not given for punishment, they are given to assure quality care.

There are but two options these employees have: Provide quality care and documentation or deal with the ramifications of their actions or inactions.

Another point: I do not allow a patient to wallow in their waste. Partially because I know that providing hygienic measures is my responsibility. Another reason is because I was incontinent of stool as a bedridden patient after an MVA when I was 19 years old and know what it feels like. I want no other individual to have to experience the physical and emotional discomfort tat I went through, so I am Johnny-on-the-Spot!

You mentioned, Marie0304, that you had regular inservices with the staff. Here's an idea: We had an inservice on the geriatric psych unit where we had to experience what bedridden wheelchair bound patients experience in order to gain empathy for some things our patients have to deal with. For example, we had to sit in a wheelchair on a small rock and not change our position. Sort of a "How would you like it if this happened to you?" sort of thing.

Once again, I admire your actions in wanting to provide quality care to those you serve and your endeavors in relaying the importance to your staff, Marie0304.

Good luck and the very best to you!