Should I find a new job asap?

[Kaysmom8]

At first I liked the job until I saw some major red flags (or what I thought to be red flags and I ignored them thinking what do I know I'm a new RN & maybe all LTC places were this way). A major incident happened yesterday when I came in for my shift & I was getting report from the day nurse & a patient's wife came to tell us that her husband was breathing funny. The nurse told her we would come & take a look at him, so this nurse tells me I don't know what that woman wants from me I've been back there all day checking his vitals & he's fine. I go into the room with her & immediately notice he's in trouble & I told her he needs to go out now because this isn't his usual behavior. He was mouth breathing, gasping for air, not talking at all & just out of it, I even saw his eyes rolling upward (which she says she didn't notice). The nurse said ok but I don't know what to tell the md because his vitals are fine. She call the md to get they approval to be sent to the hospital, now during her conversation with him she told the md perla (which she didn't check) and that he had strong pulses (she didn't check them at all, I did & I couldn't find one in his left arm and the right was very faint) she also told him his hand grasp was strong (he couldn't grasp your hand at all, his left hand was lifeless & the pads of his fingers were a funny blue discoloration) Later that night his family came to get his belongings, he had passed at the hospital. I heard a few people saying it was from an abdominal aortic aneurysm. I've never felt so bad in my life because this woman tried to tell the day nurses that this wasn't normal behavior for her husband & he suffered for several hours before I came in & made them do something about it.

[bluegeegoo2, LPN]

Many times I have come onto shift only to end up sending someone out within the hour. And many times someone has "gone bad" at shift change. It's easy to say that the last shift missed the signs, or ignored them. But as they say, feces occurs. If that nurse truly did assess the resident and spent a lot of time with the resident as she stated, then take it at face value. It is a bad habit to assume that just because you saw the resident in bad shape that he/she was in bad shape well before you arrived. Unfortunately, in LTC, we have to wait until there are obvious signs of distress before we or the MD can justify a send out. Family can and do see very subtle changes before we do. If they are insistent that there is something wrong despite assessment data pointing to the contrary, I will ask them if they would like for their loved one to be seen in the ER. (For the record, I don't fold easily. I've only sent out a few resident's that way.) If family says they want them to be seen, the Powers That Be (i.e. administrator, d.o.n., MD, etc.) will usually comply albeit with a little grumbling. All that being said, it's truly up to you whether or not you can tolerate the environment in which you work.

[CapeCodMermaid, RN]

It's apparent from many of the comments here that all y'all don't have a full understanding of the climate we're in. Heard of ACO? Hospitals are going to be penalized for readmitting patients with one of several diagnoses: CHF, MI, COPD. We need patients in our buildings or we don't get paid and no one gets a pay check. If we can't care for people and send them to the hospital at the drop of a hat, we won't get any 'good' rehab patients....we lose money...we lose positions.

My nurses know the expectation is for a thorough assessment using the SBAR and all the other INTERACT 3 tools available to keep our residents in our facility. They also know that I rely on their nursing judgment to do the right thing for the resident. The right thing is not always to send them out. If they have to go, they go.

I understand that some family members think the hospital can 'fix' a 102 year old grandma, but usually that's not the case. Every study done has shown that elders are best kept and treated in a familiar environment.

Managers have to look at the big picture which includes the financial impact of everything or YOU all won't have pay checks.

[pebbles049]

It's apparent from many of the comments here that all y'all don't have a full understanding of the climate we're in. Heard of ACO? Hospitals are going to be penalized for readmitting patients with one of several diagnoses: CHF, MI, COPD. We need patients in our buildings or we don't get paid and no one gets a pay check. If we can't care for people and send them to the hospital at the drop of a hat, we won't get any 'good' rehab patients....we lose money...we lose positions.

My nurses know the expectation is for a thorough assessment using the SBAR and all the other INTERACT 3 tools available to keep our residents in our facility. They also know that I rely on their nursing judgment to do the right thing for the resident. The right thing is not always to send them out. If they have to go, they go.

I understand that some family members think the hospital can 'fix' a 102 year old grandma, but usually that's not the case. Every study done has shown that elders are best kept and treated in a familiar environment.

Managers have to look at the big picture which includes the financial impact of everything or YOU all won't have pay checks.

In our building we were taught SBAR a long time ago. The long time nurses are usually right in sending the patients out but we have to fight with admin. One of our patients pulse ox was in the 70 -80 range when I came on and no one could get him up. CRNP in the building too. WE TRIED HARD to keep the patient in the building. The administrator who has no nursing degree and feeds patients laying down tried to keep the patient in the building after the CRNP decided he should go out. The MD said that the patient should go out. We also had another patient who needed to go out and ended up on a vent (surprise). One of the patients got into bad shape on 11-7 because the DON said to do nursing measures with patient. He was almost blue in the morning. When he gets bad like this he needs to go. It happens fast with him. Thank god I did not have him that night. I have been a nurse for over 17 years and know not to send patient to hospital right away if possible and do nursing interventions. Sorry if I sound rude but I am frustrated. I work in a building that cares about the bottom line and not the patients.

[CapeCodMermaid, RN]

I'm sorry you work in a crummy building. I work for a company that values the residents above the bottom line. If someone has to go, they go, but we know it's better for them to stay where they are so we work really hard to keep them in their home.

[kaydensmom01]

You are not alone with worrying about working in a possibly dangerous facility. I just started my first job yesterday in a SNF and was told by the nurse training me that we don't need to do assessments, that we don't need to do vitals, and that we don't need to look at labs (that we only need to fax them in to the physician when we get them and they will change a med if it needs changed). I have never worked in SNF facility so I don't know if this is expected or not because I was expecting to do a general assessment, take vitals before giving a medication such as abx or heart meds, and thought that I would have to look at relevant labs for certain meds (e.g. Coumadin). I don't want to overreact because it is SNF and you have 15 patients so I know that you can't do everything like acute care (which is my only experience). I will be with a different nurse during my orientation next week, so at least I will see if how other nurses work. Thanks for any advice.

[CapeCodMermaid, RN]

It is okay most of the time to give medications without taking vitals. Not every blood pressure med has a parameter. If someone is on short term antibiotics to treat an infection, I'd grab a temp on them. As far as labs, my nurses are supposed to look at the labs, compare them to the previous set, if any were done, and send them to the doc for review and any new orders. We don't do a head to toe assessment on every resident every day, but we do assess what they are being skilled for. You can't be faulted for doing too much, but for you to hint a place is "dangerous" because they don't take vitals before giving meds is really an overexageration.

[TheCommuter, BSN, RN]

Run for your License, I have been in the LTC/Rehab world for three years now and I am currently a nursing student and, speaking just from my personal experiences, I will never work in a rehab.

This "losing my license" mantra is terribly overrated. The vast majority of nurses do not lose their licenses over mishaps in LTC/rehab. Statistically, most nurses lose their license over drug impairment, narcotic theft, intemperate use of drugs, or drug diversion.

[Kaysmom8]

I was at the bedside when she last assessed the patient that's how I know, I'm the one that told her he needs to go out NOW.

[kaydensmom01]

It is okay most of the time to give medications without taking vitals. Not every blood pressure med has a parameter. If someone is on short term antibiotics to treat an infection, I'd grab a temp on them. As far as labs, my nurses are supposed to look at the labs, compare them to the previous set, if any were done, and send them to the doc for review and any new orders. We don't do a head to toe assessment on every resident every day, but we do assess what they are being skilled for. You can't be faulted for doing too much, but for you to hint a place is "dangerous" because they don't take vitals before giving meds is really an overexageration.

"Overexageration"? Whatever you want to think....

I'm not some naive child that believes nursing is rainbows and butterflies, I'm simply trying to find out the norm for a SNF. I've only ever had experience in acute care and was trying to see if this was the norm. I was taught to always check vital signs before administering medication that will lower the bp/pulse rate in order to prevent complications- I understand that SNF and acute care are two different things and was wondering if this is something that I should be concerned about. I understand that what I was taught in nursing school and "real" world nursing are two different things. But yes being told that assessments, vital signs, and lab result checks are not necessary on my first day in a facility certainly raised a big red flag and made me WONDER if this was dangerous practice since it was completely against anything that I have ever learned. I'm sorry that you think it is an over-exaggeration to wonder if it is dangerous to only worry about getting meds down the throats of your patients in time without knowing any of the diagnosis of the patients or even what the medications were for (my impression after yesterday). This is completely opposite of everything that I was taught so I think that it is absolutely fair to be shocked initially and wonder about the quality of care.

I didn't automatically assume the facility to be dangerous for my license, I went back and worked with another nurse today who told me pretty much opposite of what the previous nurse told me (even though the care was not at my standards but I guess I will have to lower my standards...). I didn't go into this with unrealistic expectations, or so so I thought. I went into this knowing that you have 15 patients so of course you are going to have to rush to get the med pass done, but I just thought that you would need to assess a patient at some point and would have to know about the medication that you give them (that is what a nurse does, right?). At this point I am convinced that they can just take anyone off of the street and train them to do this (not my impression in acute care). Harsh? Maybe. This is just so upsetting to me...

[CapeCodMermaid, RN]

If you re-read what I posted, I didn't call you naïve. I simply pointed out that it is NOT necessary to check the vital signs of every resident simply because they are on a med that could lower their blood pressure.

The way you practice needs to be in line with your facility's policies and the doctor's order for each resident. If you feel it necessary to take vitals, by all means, take them. But it is not a standard of practice at most long term care facilities even on a post-acute unit.

The labs are a different story....when I was a floor nurse I always reviewed the labs and now I make sure my nurses do the same, but if your facility policy states that the MD must be notified of any lab results, and the nurses fax the results to the office, technically they are following the policy. That said, I have had some nurses fax critical labs to the MD's office at 7pm which is NOT okay.

PS. I've been a nurse for more than 30 years and I still do most things the way I was taught.

[nurse4life72]

Please don't paint all LTC with the same brush. They have to make money to provide all the things residents need and employees need. The needs get more expensive while the reimbursement is drastically cut. But they are not all corrupt. I'm a LTC nurse and have been for 16 years. I love the elderly. Definately, some facilities are better than others. I would give management the opportunity to fix the problem. If it hasn't been dealt with, go to the management company. You are protected from retaliation by the Whistleblower Act.

[MountainRN53]

I'm a LTC nurse also. I have worked in over 10 different facilities in 4 different states. Some I brag about and others I do not. I resigned from the last place after 2 months of being assigned to an acute unit of 28 patients with the help of ONE CNA! I asked for help and often saw staff in the nurse station on their cell phones telling me they were busy. At times I had 3 IV's running and new admits upset they were not evaluated by therapy. I didn't worry about my license as much as not being able to provide good nursing care. My state does not recognize nurse/patient ratio. Management is the key.