What is the state guidelines for nurse to patient ratio in SNF's/LTC for California?

[ChickenJoyRN,BSN]

I am a new-grad and just started a position at a SNF in the Bay Area. I was wondering what the nurse to patient ratio, according to state guidelines, is in California. I have been working in this facility for about 2-3 weeks or so and I have to say that I am starting to regret it. I was oriented for only 2 days on the unit and they put me by myself for a PM shift. I figured I would have more time for orientation, right? Our current census is 68 patients and there are only 2 charge nurses for 3 stations. That's a 1:34 ratio!!!!

I have concerns about being overwhelmed with 34 patients with only 2 days of orientation. I still do not know how to do anything in the nurses station and all my meds are being given 2 hours late. I am worried that I may make a mistake that may jeopardize my license or even worse jeopardize a residents life!!! I'm not confident the management would have my back if something goes wrong, meaning I am placing my RN license, that I worked so hard for, at risk as I working here. I continue to ask for more days of orientation to my DON, but she insist I will do fine and start to get the hang of it soon.

I feel more on time after I have cared for about 20-25 residents. But then I think about the other 15 I have to attend to and it just get pushes back all my responsibilities. I have spoken to some of the nurses that have worked there for a long time and they said they used to have 3 nurses for each station (1:22 ratio). But not anymore:uhoh3: since the facility underwent new management.

I guess I'm looking for advice on what to do as well. I go to work scared, full of anxiety and uncertain. Now, as a new grad, I don't think that is a healthy way to begin a career. I don't want to loose my license. I originally wanted to work in a hospital, but none were taking new grads. I would be devastated if I lose my RN license over a job I didn't want in the first place. If this is the way SNF's operate, then I may have to consider looking for another one or just not consider SNF's at all.

Thanks for reading. Any advice or insight will help a lot.

[nursenow]

http://www.calnurses.org/nursing-practice/ratios/ratios_index.html

All you need to know about nursing ratios in ca,,,,,

1:5 for SNF... Dream on.

[MBA2RN, BSN, RN]

The CA Mandated Ratio Law only applies to acute care hospitals. LTCs/SNFs (all variants) and others (group homes/rest homes) aren't covered.

Remember, it might be the "Companys" facility, but it's your license. If you feel that the environment is unsafe, don't waste your time trying to change things. Nothing will change and it'll just earn you a rep as a "troublemaker". Just do your time, earn your way into a better situation when the opportunity presents itself, and don't end up as the fall-guy in a corporate failure chain.

[Delta18]

The sad part is that this is yet another COMPLETE MISS by the bone head gUvAnor of Kalifornia~he was elected to lead...not to read! This moron had an actual bill on his desk back in Jan 2008 that was slated to reduce and set the cap on the ratio of nurses to patients! His reason for not signing it at the time was to avoid the financial burdens that would hit the corporate facilities. Yeah, this from the same SOB that ended up causing the huge delay in Medicare and Medicaid payments because he couldn't play nice with the state legislature! This moron doesn't have anyones best interest at heart because his Nazi wife is shmoozed by the corporate wives and their crooked husbands! This wasn't a "political" thing until "AH-nolded" started acting like he knew how to be a competent politician!

But Kalifornia is Kalifornia - a mess due in large part to a people in office claiming best intentions for the people. But they are all segregated and do what is only best for their constituents, as opposed to doing what is RIGHT for safety!

[jackierocks]

wow, I have been feeling so alone but this thread has confirmed I am not. I recently wrote a journal about my feelings. Here it is.

I am a new graduate BSN RN in California and am counting my blessings as I was recently hired at a long term/rehab facility amidst a dreadful economy that has left thousands of my colleagues unemployed. My work thus far in long term care has confirmed my hesitancy to apply to this position though I am careful not to discount the tremendous amount of valuable learning experiences I have sustained consequently. For example I have expanded my knowledge of medications and their administrations at a personal goal of ten per week. I have also learned to manage my eight hours of work so that patient care can be performed as efficient as humanly possible with room to improve. I have learned that evidence based practice is more than a dry lecture but an essential component of thorough professional nursing of which I regretfully do not witness from many nursing staff. There is more that I have learned but what is most pressing for me is ethical care and support for it from government, nursing associations, and management at my facility.

I stop myself here because I am so new and so inexperienced and wonder if my idealistic notions are unfounded or possibly exaggerated. I am afraid however that if I do not highlight my concern early in my career that I may become too worn out, overworked, and complacent to ever feel the energy that is needed to make important changes in nursing. I currently am responsible for thirty three, yes thirty three patients who have varying diagnoses ranging from alzheimers to COPD to diabetes to epilepsy to HTN to dementia to CVA to parkinsons to pneumonia and more. Each patient may have up to ten medications each all to be administered in an ethical time frame of one hour from MD's orders. Many of these medications require pause between dosing (i.e. eye drops, inhalers, breathing treatments) as well as blood pressure, heart rate, and apical pulse assessment. Evidence may show that a full minute of apical pulse assessment is required before administration of digoxin, it may also show that manual blood pressure cuffs are more if not most accurate when compared to battery powered wrist cuffs that can be purchased from your local pharmacy. Other more basic practice based in evidence may show gloves need to me worn when administering eye drops, checking blood sugars, and cleaning wounds. What about the evidence that shows hand washing is the number one way to prevent the spread of infection during patient care though 20-30 seconds of hand washing between clients cuts approximately 20 minutes out of the shift. My cynical self believes that g-tube placement would also be shown in EBP as a first step in medication administration or feeding.

My director or nursing (who has worked all shifts) insists that the work is hard but possible. Again I can't help but pause and ask myself whether or not my inexperience is the cause of my disbelief in her claim. How could it be possible for one human to deliver quality care based in evidence to thirty three patients without acknowledging the tremendous amount of paperwork that goes along in one eight hour shift? I have many questions and a few statements, here are some.

1. Why aren't there ratios for long term care facilities?

2. I believe that if there were ratios in long term care facilities patient outcomes would be improved.

3. Many of the clients are DNR, could that be a contributing factor to the lack of regard to EBP and ethics?

4. Should we not treat these clients as aggressively, ethically, accurately as we would in a hospital or alternative time in their life per family desire?

and most importantly for me now is

5. How does one reconcile EBP, ethics, and time allotment/management?

[Neptuneschyld]

8 hr shift

In reality 7 1/2hr(450 min.) shift due to mandatory 1/2hr break.

31 patients to 1 LPN

Calculate:

450 min. divided by 31 patients equals 14.5 min. to accomplish safely and accurately all tasks required for each patient during the shift.

This time allotted for EACH patient includes and is surely not limited to:

1.The time it takes to pull medication during each medication pass, sign out the medication or pull the medication from the EDK box if the occasion calls for it, re-order medication, call a physician and write, fax, and program a medication if a patient needs a new one, and of course giving the medication which in some cases, depending on the route of administration or the mood of the patient receiving it, can be very time consuming.

2.The time it takes to gather treatment supplies (which in some cases consumes a lot of time if you have to search other floors for what you don't have), complete the treatment, and then sign off the treatment. Depending on the treatment you could be in the room with one patient anywhere from 2-5 min. (wound vac or colostomy change for example) and skin checks.

3.At the end of the night there is charting to do, inputting and addressing BM issues in the MAR, documenting any new issues into the 24 hr book, and of course the double checking of the MAR and TAR for holes at the end of the shift along with another narcotic count and giving report to the oncoming nurse.

4.Admissions! That takes a huge chunk out of the shift. HUGE! Even with another nurse coming to put together the chart, write out the medications, call the physician, get authorization to treat from family members, and gather all required paperwork for us to fill out, it can still easily take an hour at the least to complete the remaining tasks of the admission (nursing assessment, orienting the resident, consents for vaccinations, "risk for" forms, and various other assessments i.e. smoking) and put it all together.

5. Miscellaneous duties that come up in the course of a shift such as signing in medication when the pharmacy makes a delivery, and depending on the size of the delivery can be 5-10 min., handling a call or in person concern of a patient's family member which can also take 5-10 min or more depending on the concern, handling an incident whether it be fall, skin tear, or change in patient condition. This can take anywhere from 20 min. or more to collect data on the patient i.e. vitals, neurochecks, etc., call the family, call the physician, call risk management, fill out all forms required for the LPN, give the appropriate form to the CNA to fill out, write new orders for treatments or x-rays, fax, program, and call to set up the appointment for the x-ray if need be and then carry out the new treatments, and last but not least document the incident into the computer. Also, we answer call lights too, toilet residents if there is not a CNA in earshot, get ice water, etc. if the CNA's are in with another resident. There are also residents who will tell their CNA they need you and when you go in they don't have a problem, they just want to talk about what they saw on TV and gossip. Understandable because they are lonely?...yes. Do we have time to listen?... No. Addressing maintenance issues that come up. This is honestly an abridged laundry list of miscellaneous situations that come up often.

When we go into a new month, we also have monthly summaries and just prior to the new month we double note new orders into the previous and new MAR and TAR.

6. The first 1/2 hr of the shift is mostly dedicated to change over duties such as counting and signing off narcotics, getting report, assigning CNA duties for the shift, restocking straws, spoons, cups, etc. You can realistically knock off 1/2hr for the miscellaneous duties I mentioned on an average night such as, (and I'm going on the low end here) 5 min. to sign in medication from the pharmacy, 5 min. to handle "1" family member's concern, and 20 min. for an incident. In reality, on average I handle around 3 or more family concerns a shift.

When you take into consideration all that can happen in the course of a shift it doesn't really leave you with the start off allotted time of 14.5 min. per patient at all. The only way you can have that much time is if nothing "miscellaneous" happens during a shift and it is more likely than not that all of these things will happen to several patients throughout a shift. When you take off the first 1/2hr of the shift that's dedicated to change over duties and a 1/2hr of "miscellaneous" duties that can happen on an average night, the more accurate allotted time frame is closer to 12.5 min. per patient to do everything listed in #'s 1, 2,and 3. Throw in an admission which will take an hour at the least and now you have 10.6 min. to accomplish safely and accurately all tasks required for each patient during the shift.

In health care I feel there needs to be attention to detail and it is extremely difficult to impossible to give the attention needed when you're trying to complete so much in such a short amount of time.

A moment of honesty that no one wants to hear. I read posts online by many LTC nurses who state they don't actually do all ordered treatments, give patients their medications when the should, and may even omit a few because they just don't have enough time. They simply sign off that the tasks have been done. I feel it's because they want to live up to the tasks that are placed upon them and not be looked down upon for not being able accomplish them, but if no one speaks up and say's, "hey!, the time allotted per patient is an unrealistic and unsafe number," then this kind of disregard for patient safety and care will continue.

[CoffeeRTC, BSN, RN]

8 hr shift

In reality 7 1/2hr(450 min.) shift due to mandatory 1/2hr break.

31 patients to 1 LPN

Calculate:

450 min. divided by 31 patients equals 14.5 min. to accomplish safely and accurately all tasks required for each patient during the shift.

This time allotted for EACH patient includes and is surely not limited to:

1.The time it takes to pull medication during each medication pass, sign out the medication or pull the medication from the EDK box if the occasion calls for it, re-order medication, call a physician and write, fax, and program a medication if a patient needs a new one, and of course giving the medication which in some cases, depending on the route of administration or the mood of the patient receiving it, can be very time consuming.

2.The time it takes to gather treatment supplies (which in some cases consumes a lot of time if you have to search other floors for what you don't have), complete the treatment, and then sign off the treatment. Depending on the treatment you could be in the room with one patient anywhere from 2-5 min. (wound vac or colostomy change for example) and skin checks.

3.At the end of the night there is charting to do, inputting and addressing BM issues in the MAR, documenting any new issues into the 24 hr book, and of course the double checking of the MAR and TAR for holes at the end of the shift along with another narcotic count and giving report to the oncoming nurse.

4.Admissions! That takes a huge chunk out of the shift. HUGE! Even with another nurse coming to put together the chart, write out the medications, call the physician, get authorization to treat from family members, and gather all required paperwork for us to fill out, it can still easily take an hour at the least to complete the remaining tasks of the admission (nursing assessment, orienting the resident, consents for vaccinations, "risk for" forms, and various other assessments i.e. smoking) and put it all together.

5. Miscellaneous duties that come up in the course of a shift such as signing in medication when the pharmacy makes a delivery, and depending on the size of the delivery can be 5-10 min., handling a call or in person concern of a patient's family member which can also take 5-10 min or more depending on the concern, handling an incident whether it be fall, skin tear, or change in patient condition. This can take anywhere from 20 min. or more to collect data on the patient i.e. vitals, neurochecks, etc., call the family, call the physician, call risk management, fill out all forms required for the LPN, give the appropriate form to the CNA to fill out, write new orders for treatments or x-rays, fax, program, and call to set up the appointment for the x-ray if need be and then carry out the new treatments, and last but not least document the incident into the computer. Also, we answer call lights too, toilet residents if there is not a CNA in earshot, get ice water, etc. if the CNA's are in with another resident. There are also residents who will tell their CNA they need you and when you go in they don't have a problem, they just want to talk about what they saw on TV and gossip. Understandable because they are lonely?...yes. Do we have time to listen?... No. Addressing maintenance issues that come up. This is honestly an abridged laundry list of miscellaneous situations that come up often.

When we go into a new month, we also have monthly summaries and just prior to the new month we double note new orders into the previous and new MAR and TAR.

6. The first 1/2 hr of the shift is mostly dedicated to change over duties such as counting and signing off narcotics, getting report, assigning CNA duties for the shift, restocking straws, spoons, cups, etc. You can realistically knock off 1/2hr for the miscellaneous duties I mentioned on an average night such as, (and I'm going on the low end here) 5 min. to sign in medication from the pharmacy, 5 min. to handle "1" family member's concern, and 20 min. for an incident. In reality, on average I handle around 3 or more family concerns a shift.

When you take into consideration all that can happen in the course of a shift it doesn't really leave you with the start off allotted time of 14.5 min. per patient at all. The only way you can have that much time is if nothing "miscellaneous" happens during a shift and it is more likely than not that all of these things will happen to several patients throughout a shift. When you take off the first 1/2hr of the shift that's dedicated to change over duties and a 1/2hr of "miscellaneous" duties that can happen on an average night, the more accurate allotted time frame is closer to 12.5 min. per patient to do everything listed in #'s 1, 2,and 3. Throw in an admission which will take an hour at the least and now you have 10.6 min. to accomplish safely and accurately all tasks required for each patient during the shift.

In health care I feel there needs to be attention to detail and it is extremely difficult to impossible to give the attention needed when you're trying to complete so much in such a short amount of time.

A moment of honesty that no one wants to hear. I read posts online by many LTC nurses who state they don't actually do all ordered treatments, give patients their medications when the should, and may even omit a few because they just don't have enough time. They simply sign off that the tasks have been done. I feel it's because they want to live up to the tasks that are placed upon them and not be looked down upon for not being able accomplish them, but if no one speaks up and say's, "hey!, the time allotted per patient is an unrealistic and unsafe number," then this kind of disregard for patient safety and care will continue.

oh, sooo true. What about when we have the ocd resident that it takes them 45 minutes to take 3 pills or the dying resident that needs the extra attention or the staff issues that crop up. When we have a call off in the off shifts we need to make 50 calls to get no one to come in.

Yeah....the numbers are there and your math is correct. How do we get it all done?

[Neptuneschyld]

Who knows how we get it all done, but we do. We are supposed to be miracle workers I guess.

[gentlegiver, ASN, LPN, RN]

As far as I know there are no ratios for staffing in LTC/SNF/Rehab. Otherwise there would have been a very loud yell when I had 58 patients on my floor (all with various medical/mental dxs/treatments) 1 Nurse trainee, and 2 CNAs (the other 2 called out).

[gentlegiver, ASN, LPN, RN]

Who knows how we get it all done, but we do. We are supposed to be miracle workers I guess.

For our patients (even if they don't know it) we are!

[Forever Sunshine, ASN, RN]

oh, sooo true. What about when we have the ocd resident that it takes them 45 minutes to take 3 pills or the dying resident that needs the extra attention or the staff issues that crop up. When we have a call off in the off shifts we need to make 50 calls to get no one to come in.

Yeah....the numbers are there and your math is correct. How do we get it all done?

And we have a stack of orders and labs left from the day shift because.. they didnt see it until 2:55pm. And an admission rolling through the door. And exactly 3:30pm after you are coming out of the med room with a narcotic pile almost as big as you are.. someone falls on the floor. And recreation staff is telling you(while trying to get report, and collect your thoughts for 1 second so you can figure out the CNA assignments) that 4 different residents need to go to the bathroom and need to go right now. Forget even starting your 4pm medpass for 30 residents until after 6pm.

[Neptuneschyld]

And we have a stack of orders and labs left from the day shift because.. they didnt see it until 2:55pm. And an admission rolling through the door. And exactly 3:30pm after you are coming out of the med room with a narcotic pile almost as big as you are.. someone falls on the floor. And recreation staff is telling you(while trying to get report, and collect your thoughts for 1 second so you can figure out the CNA assignments) that 4 different residents need to go to the bathroom and need to go right now. Forget even starting your 4pm medpass for 30 residents until after 6pm.

Wow! sounds like we were working at the same facility, lol!

[McNabK9, BSN, RN, APN]

Reading this gives me some solace. I'm a new grad working in a snf/rehab unit for two months. There is nothing about these places that is set up for success. I am an "older" new grad with a long previous corporate career that included alot of quality process improvement work. As is typical, many of the processes where I work are never improved upon when they repeatedly fail...from staffing, to creating the schedule, to as little as have a speed dial number on the phone for the local ambulance transport. It's difficult to initiate changes because many of the other employees are invested in their way of doing things. I feel like my license is in jeoprady every day. Documentation is very important to protect yourself. Nursing notes in the charts AND keep your own documentation at home for events. Names, times, events all documented matter of factly without emotion. I know that if something happens in the snf, the scapegoat will be thrown under the bus without hesitation. In two months I've witnessed the truth be twisted repeatedly. I need a job or I won't have a place to live, but I come home every night and apply for a new one. I do believe in looking at the positive side of things, and in this case, I've learned alot about how to protect myself and the kind of nurse I don't want to be from this experience.