Some time ago I picked up PRN work at a rehab/LTC facility that ended quite poorly. I will first list my problems with the experience and then go in depth on the issue. I will draw comparisons and make stark contrasts.
Let's first start with my list of LTC issues:
- Pt to nurse ratios were completely unacceptable
- Call lights were nonstop
- Med pass consumed 6 hours of my 8-hour shift
- The MARs are illegible
- The redundancy of the charting was asinine
- The organization was in an utter disheveled state.
- Orientation is expected to end after two days of following a preceptor.
- Supplies were scarce and next to non-existent.
- Strong lack of communication between disciplines.
- Strong lack of hand sanitizing stations.
- Strong knowledge deficit of patient diagnosis and risk factors.
- Strong lack of post-rehab education.
- Illegal behavior was often promoted.
This Rehab facility had won many state and national recognition awards and boasted incessantly about their achievements. It was expected to be a wonderful new job to supplement my hours at the hospital while I wait to start my LPN-RN bridge. How wrong I turned out to be.
✔️ This particular unit had a very high acuity level. These were patients post open heart surgery and fresh strokes with complete left or right-sided deficits. These were patients with MRSA and VRE infections worse than I'd ever seen come through my ER and here we were trying to treat these poor souls. Several patients were recovering from untreatable hip fractures and needed max assist when transferring. Six of my sixteen patients had PICC lines and regularly scheduled antibiotic or TPN infusions. Every patient had a secondary diagnosis and tertiary diagnosis being simultaneously treated as well.
✔️ There was 1.5 CNAs per 16 patients (1 CNA/16 residents and 1 extra CNA per 32 residents) and that 1.5 CNAs was , understandably, always busy. The call lights went off non-stop. They never ceased to halt their infuriating chiming. During my teens and early twenties I worked in several fast food drive-thru's and heard less chiming and alarms than in this facility. Heavens forbid someone use their call light for respiratory distress, chest pain, or choking. They might not survive the 15-30 minutes it takes to answer the light. I would run room to room and attempt to assist the resident with their request but ultimately fell incredibly behind on med pass. One morning, a resident's son became very irate with our unit manager. He declared the call lights a momentous interruption during what should be a peaceful morning breakfast. The unit manager said to him there is nothing we can do about it and that everyone is already busy and working to their highest capacity to meet every residents' needs. The resident's son huffed off and eventually left the dining area muttering obscenities while his poor father heaved a drawn out sigh.
✔️ Med pass consumed 6 of my 8 hour shift. If it wasn't regularly scheduled meds I was administering, it was all the PRN meds I have to continually give out. For our stroke patients, it was not uncommon to have one or two that hadn't accepted the need for rehabilitation and they lived in a fit of anger and denial over their condition. It was 10-15 minutes minimum crushing each pill and spoon feeding it in apple sauce or yogurt. The more compassion I showed the further behind med pass I became. Compassion is not time efficient. Eventually you just give up and say you'll call the family and the doctor to notify them of the patient's non-compliance. Med pass also includes blood pressures on every single patient because every single patient is on blood pressure medication. There are no known documented ranges upon which to hold the blood pressure medication except for nursing knowledge of course. Don't forget the accuchecks for blood glucose. That accucheck machine was the most finicky piece of work I've handled to date. I cannot even describe the frustration it caused me over the course of 4 shifts. Daily weights were never before breakfast and I was lucky to get them at all. Then there were the antibiotic and TPN infusions. You had to just hope you saw it in the MAR as you skimmed through during the AM meds. Where do I wash my hands between patients and administrations?
✔️ The MARs were very much of the time illegible. Pt identifiers were lacking. Every MAR was carbon copied and at this point I realized nurses have worse handwriting than physicians. Having only been familiar with fifty or so emergency medications, I frequently found my knowledge base coming up short when I saw a new medication. What is namenda? I've never heard of it, but half of my patient load is on it! Every three to four medications there was a new medication. I was constantly shouting to the other nurse down the hall, "What is Elavil?!" Usually I could identify the first few letters of the medication and associate the medication with what was in the medication drawer under the patient's name.
At one point there had been two new admissions both by the name of Jane Doe and Jane Doey. Neither MAR had the birthday on it, Allergies were different, and both lived next door to the other. At one point I'm explaining the meds to Jane Doe and she says, "I don't have any memory problems? Why would I be taking that?" I eventually grab the MAR to list her medications to her and explain them as best as I could in my limited knowledge and she straight up said "I've never taken that before. I don't know what any of those meds are!" I eventually saw that someone had taken Jane Doe and Jane Doey's MARs and shuffled them together and their meds were no better off either. Talk about a potentially terrible medication error! I spent an unacceptably large portion of the day trying to sort through everything particularly since the doctor had made a visit and rattled off orders about one of the Jane Doe... or was it Jane Doey? I was terribly confused and eventually it was looking at the allergies it became clear who the doctor was talking about.
✔️ The charting was asenine. The amount of redundancies found in the charting was infuriating. The accucheck book and PT/INR book needed to be documented in for each accucheck / coagulation check. Then that same documentation needed to into the main MAR. In addition, every day of the week required an specialized assessment on all residents (ie: skin check Mondays; cardio-pulmonary Tuesdays; neuro Wednesdays, etc). Then there were also the residents who needed medicare charting for their specific admission condition. So the nurse was to document in MAR yes or no to weight gain in excess of 5 lbs or presence of cough for those with CHF exacerbation admissions or post op heart surgery. After charting 3 pages of "aguessments" the nurse is to go into the computer and free text every one of her assessments for focused day of the week and medicare charting. This never happened. It was left to remain in the MAR, for who really has time to double chart all that. You were lucky, as the nurse to just put in your daily accuchecks into the computer in combination with morning BPs. If, by chance something did happen and you had to make a progress note, there was a character limit in the computer. I could not exceed 980 characters. That's no more than one or two paragraphs! How do you chart an admission assessment with a 980 character limit? Hell, how do you even have time to write a 980 character assessment, many of you are probably asking right now.
✔️ To go along with the redundant charting, there was the poor organization. There was a book for doctor appointments, a book for accuchecks and coagulations, there was the MAR, there was book for pharmacy transcriptions, the book for doctor orders and 3 different bins to put the carbon copies of the doctor orders in. There was the treatment book. Then there was the Narc book and finally the patient hard chart. How many books am I supposed to look through at the beginning of my shift? Is there any book that will simply tell me why these patients are here and what their rehabilitation goals are?
A poor woman was scheduled for a paracentesis but missed two of her scheduled sessions due to lack of organization. She was in terrible shape when she finally left- she was also supposed to be NPO, but no one told me and I didn't figure it out until transport came to pick her up. I came back 3 days after her departure and what should have been a procedure that only took a few hours she was still gone away at the hospital. I keep thinking about how we all let it get by us. It was so easy to ignore her quiet demeanor, her constant replies of "no, I'm okay" and to cater to the needy more vocal residents.
One resident I dealt with during orientation had a terrible MRSA infection in his leg and was at the rehab center to help heal it up. I asked my preceptor why the patient was unable to move his upper extremities and why his Level of consciousness was down the toilet. The nurse responded, "I think he had a stroke sometime". Upon further investigation, the hospital discharge assessment made him out to be A/Ox3 with full RoM except for his affected lower extremity. Because there was no charting EVER in regards to the computer and all the MAR assessments had been put into a storage box no one was able to tell when the pt became the way he is now. So what happened to him? It obviously happened while in rehab! Whatever verbal communication had been passed down had long since been left in the dry desert of despair. This was now the way the patient is and may very well remain. Just 6 months ago he was at his grandson's baseball game, completely healthy and now the compartmentalized warehouse we store this man in is cold, heartless, and neglectful.
✔️ Finally, after two days of orientation it is time for the new nurse to become self-sufficient! Here you go, Nurse Mary! 16 patients all for you! You will love them and they will love you. Don't forget the dressing changes in room 2,4,6,8. Room 10 and 12 have colostomy bags that keep leaking, so you'll probably have to replace them before the end of your shift. Oh, where is that forsaken hand washing station? I have just been cleaning colostomy sites for the last half hour!
✔️ Supplies were so scarce. Perhaps, Like my imaginary Nurse Mary, I was too new to know where to look or we were just short in stock. It was just that simple. So little to work with.
✔️ There was a strong lack of communication between disciplines. I never knew the PT / OT therapy schedule of my residents. Even if there was a sheet, where would it have been located? I already have six or seven binders I need to look at each morning and thus transcribe all of it on to my brain sheet. Things could go so much better if I was allowed to just premedicate my patients prior to the Physical and occupational therapies. Finally, we should find a way to communicate the patient's goals during therapy. Perhaps, as a nurse, if I ever break away from the med cart, I can encourage the patient to stay on track with their recommended exercises. We can help each other and benefit the patient. Instead, I'm always thrown under the bus for giving poor nursing care and glared at by the PTs and OTs. These looks of frustration and anger make me feel dirty...
✔️ Seriously, now! Where is that freaking hand washing station!? For a hall with 16 residents there is one hand sanitizing station. There are no other hand sanitizer dispensers. The only sinks are in the resident's rooms and those are frequently cluttered with all their personal hygiene materials and the sink itself just doesn't look the best with all their flaking skin and hair oh forget it... I'm going to wash my hands. I can't deal with this. I go to reach the faucet with a paper towel covering my hand so I don't touch the faucet. In using the paper towel the extra length of the towel clips a perfume container and it falls to the ground shattering. The resident is unimaginably angry... wait, I'm trying to wash my hands in the personal sink of someone who has... C-diff? Really? This is so messed up on so many levels.
✔️ There is a strong knowledge deficit on patient diagnoses and their associated risk factors. Most of the staff has no idea why their patients are here or what their co morbidities are. If you are a nurse who is new to the unit, you may be requested to perform any number of treatments or procedures and next thing you know you'll be forced to put an NG tube down a guy with esophageal vertices. You'll cause excessive bleeding and he'll expire. Then the DoN will blame it all on you because you should have known he had the esophageal verices, but the patient was non-verbal so how were you to have known? His chart is all on paper, the admission assessment that should have had a list of diagnoses and pt admission statuses is limited to a 980 character limit!! It's not until you look back over 40 pages of physician progress notes you finally find a Dx of esophageal vertices that was inexplicably left out in more recent Dx's. Oh the excitement you are in for, Nurse Mary!
✔️ In the middle of your day you have a discharge for room 3. Your discharge instructions must be manually typed with a list of all medications the patient is currently taking. The patient must be made aware through these discharge instructions what the medication is for, how much to take, and when to take it. There is no further education regarding the patient's original rehab diagnosis for who really knows why the patient was really here anyways, rt?
✔️ While taking meds from another resident to supply your current resident with the same or equivalent prescription is common, it is still illegal and should not be encouraged. Yet, here we are. State regulations prohibit administering medications during meal times, yet we do it all the time. This isn't a feasible system.
NOW LET'S TRY TO SOLVE THIS PROBLEM....
When I entered nursing school, I heard repeatedly how we should not be in nursing for the money because there is not a lot of money in nursing. I expected that. I even expected less because I was going to become an LPN ( "Low Paid Nurse" ) but I was going to take much pride in my work and I was going to make a difference!
My first job at a correctional facility paid me $14.96 / hr. My first job within a hospital setting paid me $13.69 / hr. This was significantly less than I ever anticipated as an LPN, however, I was still making a difference and I was having fun doing it, knowing I made a difference today.
If LTC reduced their LPN wages to match that of the non-LTC facilities to about $14/hr and hired more LPNs at that rate then there would be a much higher nurse to patient ratio. I know CNAs that make more than $14/hr in LTC. That is crazy! I'm a nurse and they're making more than myself!
So if I had only 8 patients and another LPN took my other 8 patients we wouldn't have to do "aguessments" but rather real "assessments". Perhaps accurate documentation could be performed and we would know what happened to that gentleman with MRSA infection in his leg. With an extra nurse, I could keep on top of my patient's pain. I could potentially, look through all those books and figure out who needs what and when they need it. Perhaps skin break down wouldn't be such a huge issue. Maybe I develop that rapport with my patients that I always wanted. Maybe I could actually learn about all these meds I'm unwittingly administering!
Maybe the patient in room 11 wouldn't have to keep reminding staff that she's supposed to be receiving an IV vanc infusion but for the last 3 days no one has remembered to order it and now she's screaming at the top of her lungs to speak with management. How do we explain this? Heck, I just walked in. Maybe we should ask why it wasn't written in the MAR but only in the treatment book?
Maybe I'll find the time to finally speak with management about the lack of hand sanitation stations!! How glorious that would be. Have you heard about that new CRE out there? The Carbapenem-resistant enterobacteriaceae? Yeah, kinda scary. I think hand washing is very important.
Yes, I think that would help out immensely. We are nurses to help people. We are not in nursing for the money. It was instilled in us from day one that nurses don't make any money. I know this and you know this. Let's make a difference. As long as I love my job and get a raise every year, say around 4%, then my pay check will grow every year with my experience. Retention of nursing staff will increase as well as patient satisfaction. Rapports and relationships will be made and state regulations will be adhered on a more strict basis, although I still see us administering meds every now and then when we fall behind to a resident during his/her meal.
Yes, let's fix this! I believe there are enough new grads out there that want a job bad enough and want to learn about a wide array of procedures like bipap, EKG's, blood draws, NG tube insertion, etc and will take a lower paying job for job satisfaction and reap financial rewards for their job well-done. (More) Accurate charting will be performed and MDS can capture more costs to gain more money!
Yet, I don't see this where LPNs are concerned.
My friend went to a LTC facility for pediatric hospice and rehab patients as an RN student nurse. It was an all RN staff. There were no LPNs. Each RN was assigned to eight patients similarly to my own idea, but there was a Qualified Medications Aide working under the RN to pass prescribed medications to the RNs patients. The RN was to assess the patient, take vitals, weights, and work with the interdisciplinary team to create appropriate goals, and authorize PRN meds. This is how it should be!
Why do the RNs have this all figured out? And how much are they making? Not $14/hr. I constantly feel like areas of nursing where LPNs dominate are the areas of nursing no one wants to ever be at.
I feel like the LPN role is to fill in the niche of nursing the majority of nurses have no interest in. Yes, this may be an overly broad generalization but my primary job rarely refers to me as an LPN, but rather tells me daily what I'm not, and that is a "non-RN". So there will always be a rivalry when my official designation on the schedule is "non-RN" and when an all RN staff in LTC get to make use of QMAs and get to focus on their 8 patients and discuss goals, education, and perform assessments. I am jealous and angry that RNs in an all RN setting are so frequently set up for success while areas dominated by LPNs are set up for failure. Bah, weak argument here but the point I'm trying to make, is I feel LPNs get the short end of the stick when it comes to nursing.
Okay, enough about that, back on track. (and yes, for those who are going to say, "why don't you just become an RN then" I will reply back with, "I'm already in the process, thank you!")
Another idea for LTC would be to have one nurse be a "med nurse" and pass all scheduled and prn meds while the other nurse assesses, educates, and performs treatments. I heard one of my coworkers discussing at the hospital how before there was the Pyxis, there would be a med nurse for the unit, a treatment nurse, and a nurse to do just assessments and charting of assessments. I think that plan sounds rather feasible as well.
Next thing, I think there should be a standardized scope of practice across the USA for all RNs and LPNs. I was constantly feeling conflicted with my hospital training vs what the LTC facility wanted of me. At the hospital I draw blood from PICC lines all the time while the LTC facility was very adamant that it be an RN. At the hospital I'm not allowed to hang any kind of cardiac drug, at the LTC facility there was someone on Levophed- and he was awake! This was part of the critical care unit at the facility. I've always heard "Levophed, leave 'em dead". Like are you serious? At the hospital I can hang blood under my own license. At the LTC facility I'm not supposed to. It gets so conflicting. At the LTC facility it said I'm not allowed to start IVs without an IV certification. My state doesn't require an IV certification for an LPN to perform IV therapy. So, the LTC facility would just blatantly ignore its own rule. The hospital says an LPN cannot assess, while the LTC facility demands I assess! Assess! ASSESS!! I already made a post that received almost no replies on the difference between data collection and assessments. I suppose it was just so ludicrous to think an LPN can't assess that it wasn't worthy of any replies as I'm sure this post will be so long no one will read and thus replies will be limited. HAHAHA. I've been typing for 3 hours. I still feel like I have so much more to say but I'm starting to ramble.
Someone is going to say that my experience isn't the typical LTC experience. That is correct. Many LTC facilities are not SNF's, or rehab, etc. The resident is just an elderly, frail, person who needs a little guidance and reminder to take all their meds- but that has not been my experience.
And working in the ER, when I get report from a LTC nurse, it generally results in a lot of eye rolling. Seriously who continues to give Norco's for a fever to a dialysis pt and then wonder why she's become lethargic.
I hate LTC.
Please tell me of a LTC facility where things run smoothly, nurse's understand their patient's needs, and make a difference; where the resident is not just thrown away to a corner while you move onwards. I want to hear of a place where real life is reflected on the billboard I pass every day on the interstate with the smiling nurse and the resident is laughing at some cosmic joke I'm only just beginning to understand.
