what to do.....

  1. So. I've posted on here enough times with my opinion about a variety of LTC issues. I am at my wits' end now. I've been a DNS for about 4 1/2 months and it seems no matter how hard I try to make things better at my facility, nothing changes. We've had more inservices since I started than they did in 2 years before that....has it made a difference? NOPE...same nurses still doing the same things....maybe one person in the building has stepped up. They all complain that we won't do well at survey time but yet no one seems to think it is up to them to help fix things. Please no one take offense, but in this state LPN school is 11 months and in LTC their scope of practice is almost identical to the RN...with the exception of pronouncing some one dead, and let's face it, THAT's pretty easy...don't need great assessment skills to know when dead is dead.
    I had an interview with a brand new RN...no experience except the little she got in school and she wanted to work on the subacute floor. I told her I didn't want her first nursing job to be horrible and if she took the job with the 20 patients for meds,treatments, labs, orders and everything else that goes with it, she would hate it. My co workers said I should hire anyone who has a license basically...what would all y'all do? I can't lie and tell these nurses it's an easy job.
    I'm so discouraged that I wish I never even took the job. I'm leaving next week to go to a different kind of nursing but I feel like a failure. The corporation is telling me what a wonderful job I've done in a short time....wonderful? Nurses still fax labs to MD offices at 3 am...I don't know about all y'all, but MY doctor is NOT in her office at 3 am, and it seems no matter what I say or what classes we provide, they still won't or can't learn. Do we expect so little of people these days that any thing is OKAY as long as they show up and pass meds?
    I don't really think anyone has an answer, but I feel somewhat better for having spouted off.:smackingf :deadhorse
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  2. 28 Comments

  3. by   fultzymom
    I am having a problem similar but not the exact same. I took over MDS et skilled nursing in my facility. I revamped the nurse notes to make them easier, put in charting guidelines so that they will know what to gear their charting towards for each patient et what they are there for, and am constantly in contact with the floor nurses making sure they have what they need et know what is going on with each patient skilling wise. Just the other day, a couple of them told me that they do not understand or see the point of what we are doing et they are just flat out not going to do it. If is very frustrating because our charting is one thing that has come up at state inspection et we have a woman who comes in for chart review who looks at our charting like state does. She also says that we are not sure where we need to be. I am at my wits end with it and it has only been since November since I started!! Very frustrating! Not sure what to do to get everything where it needs to be.
  4. by   Nascar nurse
    I'm with you. LTC is just increasingly frustrating. I think I am slowly accepting that there is just no hope for our current LTC standards. In my facility anyways, it seems like there are only about 25% of the nurses with any REAL nursing skills. The rest have blinders on and just look to pass meds without using any level of a higher thinking process. Would seem that common sense isn't so common. Example - dementia resident very agitated, constantly trying to get out of chair unassisted, constantly setting off alarms. When I took my turn to redirect, resident tells me I have to poop. Aide and nurse nearby state we've taken her 3 times in last hour and she just sits there. End result... the poor lady has got poop up to her eyballs and no one thought to check if maybe she was constipated. They thought pain in the a$$, but couldn't figure out that it REALLY WAS a pain in the a$$:roll. Of course once she was cleaned out, she was at least more manageable behavior wise.

    Couple of months ago I read an article in Readers Digest that basically "slammed" long term care residents. Had example of people dieing of fecal impactions, infected bedsores and all the usual "stuff". My first gut reaction was "Here we go again, more BS about how horrible LTC is", but the reality is - IT IS THAT BAD. Now I think I am fortunate as I work in a facility that physical/mental abuse etc is absolutely not tolerated and rarely to never occurs and for the most part, all the staff (aides, nurses, even housekeepers etc) are a very caring bunch, BUT we need more INTELLIGENT PROFESSIONAL nurses that can think beyond what is in front of their nose.

    Another example: I was casually going thru the lab work that was stacked at the station and noted that resident had INR of 7 something. Tracked down the nurse and asked if they had called MD... "No. I'll get to that in a little while". Explained INR of 7 is potentially pretty dang serious and MD needs notified now. Also told this nurse to go assess resident to make sure no bleeding. Nurse stalls and eventually says "Can't. She just left to go to the dentist for teeth extractions" Turns out the nurse HAD actually read the lab report prior to the resident ever leaving the facility and just never occured that this might be a poor decision. WHY WHY WHY?? I could go on and on w/ examples like this.

    So, despite all my rambling... what is the solution? How do we obtain and retain a higher class of nursing professionals. Some say it's all about staffing and I agree staffing ratios may help to some point - but I have seen time and time again, when staffing is great for a day everyone seems to goof off just a little more cuz the pressure is off. (Yes, I know there are some of you working under HORRIBLE staffing ratios and more staff would make huge improvements. But I think a 20:1 of relatively stable residents is doable on most days. Been there/done it).

    So who has got ideas? Someday we will be old and we will be stuck in our own broken system. Sorry, I'm rarely this long winded, but this topic touches a nerve.
  5. by   TammyArkansas
    Oh, exactly! I feel your pain. That's why I posted a thread about Legislation in LTC recently. (But no one responded). I am through complaining because the budget of the Nursing Home Owners/Administration is not conducive to bedside care that is needed. It's going to have to come down to LAWS and MORE of them. Yes I also already HATE it when state comes in. I'm the MDS Coordinator and I care what kind of work I produce. I do not stand around gossiping nor do I take smoke breaks. Actually never had taken an actual go outside and breathe break. However, I do eat my granola bar at my desk around 10-11 most days. Just today the interim administrator, who was brought in by Corporate since the NICE female adminis was let go because we got tagged by state on some things, said there is enough hours in the day to do everything she is telling us to do. BUT they only want us to work 7.5 hours/day. I'll tell you what my facility needs: Updated computer hardware that doesn't freeze, lockup, and lose precious, time consuming MDS data; the money to pay decent salaries to LPNs to fill the shifts so the other MDS Coordinator can actually help me instead of being pulled to the floor for numerous things, like: treatments, training a new nurse, working a called-in shift, etc. We also need not to be pulled away from our MDS/Careplan/Medicare duties to do: meal monitoring, inspection action rounds, compliance confirmations, etc. Oh my goodness....it goes on and on....doesn't it. Today in our Stand Up meeting, after the militant administrator told us there are enough hours in the day to do all she demands, I asked her what is my priority: MDS, careplans, or inspection rounds. She said the am rounds. I told her I fear later when we are asked why something is not done, I will be reprimanded. She did not accept that. Treats us like dogs, worse than dogs, so rude and condescending. She leaves no room for negotiation. UGH!
  6. by   catlover13
    I think one of the keys to successful change, is to have the employees take charge of the changes.

    I think that some nice groundwork has been laid by you, that is the reasoning behind the changes.

    Now it is time to take it to the next level - for the nurses - how are they going to implement and incorporate these changes.

    The realization must be made that these are NOT suggestions, but new standards of practice, and are requirements.

    Reward for a job well done, listen and respond to employee concerns during the change process, just because something seems great in theory, it still may need to be tweaked.

    And lastly, and also unfortunately, there must be consequences for not performing the duties as expected. There may need to be some pruning of staff who are unwilling to embrace change.

    Stress and find a way for the staff to feel as if they have ownership of these changes.

    Hope this helps...

    Lynn
  7. by   Simplepleasures
    Quote from TammyArkansas
    Oh, exactly! I feel your pain. That's why I posted a thread about Legislation in LTC recently. (But no one responded). I am through complaining because the budget of the Nursing Home Owners/Administration is not conducive to bedside care that is needed. It's going to have to come down to LAWS and MORE of them. Yes I also already HATE it when state comes in. I'm the MDS Coordinator and I care what kind of work I produce. I do not stand around gossiping nor do I take smoke breaks. Actually never had taken an actual go outside and breathe break. However, I do eat my granola bar at my desk around 10-11 most days. Just today the interim administrator, who was brought in by Corporate since the NICE female adminis was let go because we got tagged by state on some things, said there is enough hours in the day to do everything she is telling us to do. BUT they only want us to work 7.5 hours/day. I'll tell you what my facility needs: Updated computer hardware that doesn't freeze, lockup, and lose precious, time consuming MDS data; the money to pay decent salaries to LPNs to fill the shifts so the other MDS Coordinator can actually help me instead of being pulled to the floor for numerous things, like: treatments, training a new nurse, working a called-in shift, etc. We also need not to be pulled away from our MDS/Careplan/Medicare duties to do: meal monitoring, inspection action rounds, compliance confirmations, etc. Oh my goodness....it goes on and on....doesn't it. Today in our Stand Up meeting, after the militant administrator told us there are enough hours in the day to do all she demands, I asked her what is my priority: MDS, careplans, or inspection rounds. She said the am rounds. I told her I fear later when we are asked why something is not done, I will be reprimanded. She did not accept that. Treats us like dogs, worse than dogs, so rude and condescending. She leaves no room for negotiation. UGH!
    I am sorry no one replied to the post you refer to. The things that you have suggested have been suggested before by several of us that post on this LTC forum pretty often. Every thing you did bring up in that post is "right on". I have been in contact with nursing home reform people all over this country and the general consensus is that until we get out from under the powerful lobby of the multi billion dollar a year healthcare industry and a new congress NOTHING is going to happen. There are propositions that DO address these issues, but have not been acted upon in the last 6 years, due to this conserative administration. I have HOPE that with the new congress and the possiblility of a new liberal administration in 2008 , these issues will finally be brought in front of a voting body.
    Last edit by Simplepleasures on Jan 31, '07
  8. by   TammyArkansas
    i have been in contact with nursing home reform people all over this country and the general consensus is that until we get out from under the powerful lobby of the multi billion dollar a year healthcare industry and a new congress nothing is going to happen. there are propositions that do address these issues, but have not been acted upon in the last 6 years, due to this conserative administration. i have hope that with the new congress and the possiblility of a new liberal administration in 2008 , these issues will finally be brought in front of a voting body.

    thanks for the info, ingelein. good, re: hope with a new congress. i don't understand why the repub congress did not pass more legislation. those politicians are also sons and daughters of elderly people (who are the majority of nsg home/rehab residents), so they should realize the problems and should want to correct them or at least try. when it comes to money vs. the treatment of your loved ones, where's the difficult decision? it's beyond me.
  9. by   TammyArkansas
    Yes, sadly to say, some administrators and DONs will keep, shall we say, "not the brightest" bedside nurses and CNAs because they fill the shift slot numbers. It would be great if the people with a conscience and caring hearts ran the individual nursing homes, were district mgrs, were corporate, etc. I agree it is very frustrating. Do your best until it pushes you to resignation, I suppose. God Bless.
  10. by   CapeCodMermaid
    Because of the stigma and bad rap LTC has, most of the nurses we have applying are 'not the brightest'. I'd love to fill my facility with smart nurses, but there are none applying. And by the way, having just been a patient in a hospital, I didn't find anyone there was overburdened with brains either.
  11. by   Simplepleasures
    Quote from CapeCodMermaid
    Because of the stigma and bad rap LTC has, most of the nurses we have applying are 'not the brightest'. I'd love to fill my facility with smart nurses, but there are none applying. And by the way, having just been a patient in a hospital, I didn't find anyone there was overburdened with brains either.
    Oh man, this IS scary, I can see wards and wards of lobotomized nurses roaming the halls aimlessly...:uhoh21:
  12. by   rehab nurse
    CapeCod,

    Well, I've worked rehab, subacute rehab most of my career. I did a short stint in L&D and it just wasn't for me. I love rehab, but at my last job (which i was just let go for using FMLA time) I was one of two nurses that worked our tails off. I would be honored to work with a DON/DNS like you who actually shares my views. My last DON is not seen, only heard when she writes someone up for a ridiculous issue. She rewards some of the laziest, not-so-smart nurses in the building. I know I probably sound totally stuck-up, snobby, and rude. But really...they have no common sense. I'll give you a few examples if you don't believe me.

    1. RN writes in LOG BOOK for MD: pt with fever 103.7, crackles in left lower lobe, SOB at rest and with exertion. He did not see it for two days, and none of the nurses who took care of this poor patient did ANYTHING about it either. Why wouldn't you call an MD with this info? Poor lady ended up in the hospital despite trying to keep her there on IV abt, o2, etc.

    2. An admission that had travelled from another state (very unusual in out setting) for almost 3 hours. Came in at 10am, was admitted for therapy after being in a motorcycle accident. Had severe pain, broken ribs, broken pelvis, cracked vertebrae, etc. Had transfer orders for oxycodone and morphine. Despite this poor man c/o pain to the RN in charge of him since 10 am, she refused to medicate him. I came in at 3, and I was the one who went to the backup narcotic box and got this poor man some meds. I had to give him a whole lot extra (with orders of course) to get his pain under control. The admission orders weren't written out, the admission assessment was not started at ALL, nothing. None of the admission was even started. She was sitting in the office eating popcorn and drinking a soda when I came in, laughing with her coworker LPN. I was so angry, and despite complaining and the pt making complaints, the DON refused to say anything. Sorry, but patients in pain who are left to suffer just touch a nerve with me.

    This is already too long, but I was continually left more and more work from these particular nurses. Despite our own shift having less than half the staff of days, we were left with orders, even STAT or NOW orders, from MD rounds at 8am. Yes, 8 am. More than a dozen times. I made copies, complained, nothing happened. MD's complained, nothing happens. Admissions left for us with nothing done. Now, I understand it may happen once in a while. I know things happen. But EVERY day? Admission coming in at 1pm or 2pm, I can understand not having time. But at 10 am? 11am? And all I am asking is to do the meds (because it takes about 12 hours to get pharm delivery) and MAYBE the initial assessment. Sorry, but a patient should at LEAST have a nurse in their room doing an assessment of basic needs when they come in. Can you imagine being left in pain for 5 hours before you get any relief?

    Sorry this was such a rant. But CapeCod, I've read a lot of your posts, and you sound like a director that's got a good head on her shoulders. All your asking is for some work, some common sense, some nurses who do what we were taught to do. Nothing wrong with that. I too see incredibly lacking nurses where I used to work. Patients suffered because of it. I'm not talking about nurses who are just new and need a little time, I'm talking scary nothing-ever-changes nurses. I don't know what the answers are. Hell, I wish I still had my job. I really did love it. I hear from a couple nurses who still work there and it has only gotten horribly worse. I don't know what the answer is. I know there are SO many great nurses out there that work their butts off in a very less-than-respected area, and I take my hats off to you. I would love to work with the nurses on this board any day.

    CapeCod I would love to work for you. Where do you live? LOL.
  13. by   CapeCodMermaid
    Thanks for the kind words. I live on Cape Cod(hence the screen name). I'd love to hire good nurses, but the job has become too frustrating for me....I am losing sleep and having chest pains, and stomach aches from the stress. My last day as DNS is next week and I will be going to work for a home health agency where I don't have to worry about anyone but me and my patients. My friends and boss tell me that I'll be bored and won't like being a 'regular' worker as opposed to management. I am SO looking forward to being 'regular'!!
  14. by   banditrn
    Quote from CapeCodMermaid
    Because of the stigma and bad rap LTC has, most of the nurses we have applying are 'not the brightest'. I'd love to fill my facility with smart nurses, but there are none applying. And by the way, having just been a patient in a hospital, I didn't find anyone there was overburdened with brains either.
    Capecod - I take exception to this - I'm a very bright girl, lots of experience, etc., etc. But what I've come to realize is this isn't what I was hired for - it's the 'RN' after my name.

    Our facility apparently doesn't DO inservices - we recently accepted a patient with a trach - and I came to realize that some of the girls there HAD NO EXPERIENCE with this type of patient. Yet the guy was just brought in one night and dumped on a new LPN! It took me two days to get ahold of the DON and ask her what she planned to do about it? And a policy and procedure manual? I asked her where it was - it's in her office - she's trying to update it.

    When they DO get someone new - the older nurses beat them down until they don't know the right way to do things - and again, I think this is a problem with the DON and management. Just having 17 years experience in the same place does NOT a good nurse make - I had an argument with a day LPN the other day about giving a LOL morphine - it gives her hallucinations - I told her that was unacceptable, and she needed to call the doc. She told me morphine was a good drug - well, yes, it is, but there are other things that could be done that would be better.

    The management has no real idea what the nurses do - it just seems like they want to cram in more and more people to increase the profits. The unit I work is up to 43 patients, and they're thinking that they could possibly add more.

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