Can anyone help me understand patient ratios?

  1. I am a new nurse. I work in a nursing home/rehab facility. I am beginning to think we are definately making huge errors in our facility. I work the full time 3-11 position in a 25 bed hall. It was at one time strictly long term care. It is now a big befuddled mess if you ask me!
    They are "converting" my hall supposedly to a cardiac rehab wing. At least that is what I was told we were doing. So far not so much! I am not even sure what cardiac rehab means right now!
    This facility has already "shut down" its dementia unit. Yeah they decided it was a good idea to just put all the dementia patients in whatever empty beds were in the other long term halls. (you can imagine all the problems this in itself has created for everyone concerned)
    They "upgraded" the old dementia unit to a "higher end" rehab unit. (Much more money for facility) They did add extra staff over there to "meet the demands of the higher paying customers" The aid to patient ratio is about a max of 8 patients per aid and their is a second nurse from 11a- 7p for a 30 bed unit.

    Well somehow my hall (now nicknamed "send em all home crying hell hall") has become the "rehab overflow" hall. I still have a few LTC patients, some dementia patients,also hospice and increasingly more "rehab overflow" patients. It is just me the LPN and two aids for these 25 beds.
    In a LTC hall only this would be okay with the occasional "bad night". (I have also filled in on those halls and found it to be a vacation even on what THEY call a bad night)
    The MAJORITY of my "rehab" patients are NOT cardiac! I think I have only had two in three months. These people are "train wrecks" when they get here. A lot of them I am scared to death because the reality is they should NOT be out of the hospital yet. They are barely stable. They are coming to me still full of staples, G-tubes, wound vacs, wet to dry dressings, trachs, IV medications (which the facility has YET to certify me for so I must run track down either the RN super or someone certified to hang these darn things) Hoyer lifts, fresh amputees, you name it they are sent here.
    To make things even more fun they eliminated our unit secretary and dumped her job on us as well. They also refuse to hire an admissions nurse so that is also my job, (assessments, care plans and all) They do not limit WHEN admissions can come nor how many at a time. We LPN's are also responsible for going to the dining rooms at supper to help there and make sure no one chokes etc (really WHO is watching all my patients that are eating in their rooms so they don't choke?) They do not put additional staff on on Fridays AKA "hospital dump day" to help handle all the new admissions that we are going to get slammed with. They do not seem to even screen the new patients at all. SO frequently I am sent "rehab" patients that ALSO have dementia, schizophrenia or bipolar disorder, are NOT stable on their psych meds have multiple behavioral issues, including violence. So I get all kinds of "surprises" thrown at me when I do try to assess them.
    When we ask for help we are told to quit complaining. We are lucky here. The aid to patient ratio is 18 to one and each of our aids "only" have 13. I am not even sure what the patient to nurse ratio is but it must be over at least 33 to one because one of our LTC halls has 33 beds and we never got in trouble with the state for that.
    So who decided these ratios? Does it matter WHAT TYPE of patients are being put at the ratio of 25 to 1 nurse and 13 to one aid? What about all the patients that require two aids for care and transfers etc? Is there a limit to how many of them can be mixed in with the one assist patients? Is there a limit to how many psych patients or dementia patients a nurse needs to protect the other patients from in one hall? Is there rule that changes the ratios based on the level of care these patients require?
    This situation is beyond dangerous for all concerned. It is beyond out of control. The double talk from the higher ups leaves you with your head spinning ever time they yell at you. THEY don't know what to do with the mess they have created is what I have concluded. Someone has to take the blame and I am at the bottom of the totem pole I guess.
    Indeed this past week has me looking for another job in another facility. We had a terrible incident happen and the "meeting" with the acting administrator and one of the day time RN supervisors left me in terror of working for these people. I followed protocol for dealing with a dementia patient that was acting behavioral but not violent. She was simply trying to get out of her chair. (my butt would hurt too if I had to sit all day every day in a chair) No biting spitting kicking punching etc. ONLY trying to get up repeatedly. Toileting, taking for brief walks as she could physically tolerate before having to sit from buckling knees, snacks, puzzles etc. She gets routine ativan 2 times on my shift. None on the other shifts. She had a PRN order for ativan as well with a not to exceed in 24 hour period parameter. (if divided into three shifts I am maxed on on my allowed amount for my shift anyway but no RN super would give me a straight answer on whether I am allowed to use PRN or not on my shift due to this) Still we must go through all the non medication interventions before resorting to PRN anyway. SO my patient comes back from supper and is doing the same thing. In 15 minutes she is due for her routine ativan. Began the non medication interventions, toileting, short walk, time for routine, family members freaking out, ask aid that is sitting at desk doing nothing to watch patient until I can get caught up,RN super busy sending someone out to hospital on another hall. Well someone decided to weave her sweater through the back of the chair she was in (physical restraint) while I was dealing with the worked up family member and rushing to give all the meds to all the patients I know have NO patience whatsoever and will also make scene if they do not get them at the exact same time every day.
    SO I am being screamed at over and over for not using her PRN ativan. I restate that she had routine on my shift and I did not want to overdose her by giving PRN so close to routine before or after the routine dose. It didn't even have a chance to work yet when I asked the aid to watch her for me. She kept yelling at me and said "Now see we have a problem here! You not using her PRN ativan caused an aid to become frustrated with her and caused her to physically restrain a patient" This is state reportable offense!" "it can cost you your license!" I reiterated that she was not violent in any way, only trying to get up. "She says "I am not telling you to chemically restrain anyone" (REAAALLY? it sure SOUNDS like that is what I am being screamed at for not doing?) I got screamed at for not trusting the aids and screamed at for trusting the aids after all they have a license to and are trained. I got screamed at for taking responsibility and screamed at for NOT dumping responsibility on my RN super. Yeah my head was spinning when I left there. I was on suspension with all three aids that had direct contact with the patient because how can they know it wasn't me that tied her to the chair? REALLY? Does it make an ounce of sense to ask an aid to watch her for me if I was going to tie her to a chair in the first place? The next day I go back for a second interview with the regional DON and am thanked by her for everything I did that got me screamed at the day before by the Acting administrator and RN super.She said she is even shocked that I would do direct care on a patient (toileted her to try to make her comfortable while the aids were still collecting supper trays from the floor) She appreciates that I was trying all non medication interventions. She said she is confident that I did not tie my patient fast to a chair and could come back to work my next scheduled day. The actual administrator was there the second day and said "yeah if you still want to work here". Umm no I do NOT want to still work here. I am scared to death to come to work every single day as it is but I have no choice unless I can find another job. For all I know it is exactly the same everywhere and going to school to be an LPN was the biggest mistake of my life. That is what went through my mind but of course I say nothing.
    If there were not so many different type of patients with so many different needs and demands down my hall along with screaming demanding family members that are sure they are the only ones there creating so much chaos every minute of every day this would not have happened in the first place.
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  2. 18 Comments

  3. by   sapphire18
    I am so sorry that your job is so stressful- I don't know how anyone handles ratios like that. I'm glad that the regional DON saw that you were doing the right thing and not the one to restrain the patient. Since you did NOT restrain the patient, you have no reason to worry about your license- it sounds like the CNA should be in trouble though. I don't really have anything helpful to add as I have never worked in LTC, but I just want to offer my support and wish you luck in finding another job, and that in the meantime your job is a little better for you.
  4. by   Esme12
    Your State. The government.....Health and Human Services. The Joint Commission. The Department of Health in your state. The Center for Medicare and Medicaid Services. HOW they decide it...is beyond me.

    State Long-Term Care: Recent Developments and Policy Directions
    State-Initiated Nursing Home Nurse Staffing Ratios: Annotated Review of the Literature
    Medicare.gov - Nursing Home Compare - Nursing Home Important Information
    SB972 - Outlines minimum staffing requirements for skilled nursing facilities
    http://www.theconsumervoice.org/site...table-2010.pdf

    Nursing homes that receive federal funds must comply with federal legislation that calls for a high quality of care. Though all states must comply, at a minimum, with the federal regulations, some states have adopted tougher laws.

    To participate in the Medicare and Medicaid programs, nursing homes must comply with the federal requirements for long term care facilities. Federal Regulations and Nursing Homes

    Under the regulations, the nursing home must:
    • Have sufficient nursing staff. (42 CFR 483.30)
    • Conduct initially a comprehensive and accurate assessment of each resident's functional capacity. (42 CFR 483.20)
    • Develop a comprehensive care plan for each resident. (42 CFR 483.20)
    • Prevent the deterioration of a resident's ability to bathe, dress, groom, transfer and ambulate, toilet, eat, and to communicate. (42 CFR 483.25)
    • Provide, if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene. (42 CFR 483.25)
    • Ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. (42 CFR 483.25)
    • Ensure that residents do not develop pressure sores and, if a resident has pressure sores, provide the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. (42 CFR 483.25)
    • Provide appropriate treatment and services to incontinent residents to restore as much normal bladder functioning as possible. (42 CFR 483.25)
    • Ensure that the resident receives adequate supervision and assistive devices to prevent accidents. (42 CFR 483.25)
    • Maintain acceptable parameters of nutritional status. (42 CFR 483.25)
    • Provide each resident with sufficient fluid intake to maintain proper hydration and health. (42 CFR 483.25)
    • Ensure that residents are free of any significant medication errors. (42 CFR 483.25)
    • Promote each resident's quality of life. (42 CFR 483.15)
    • Maintain dignity and respect of each resident. (42 CFR 483.15)
    • Ensure that the resident has the right to choose activities, schedules, and health care. (42 CFR 483.40)
    • Provide pharmaceutical services to meet the needs of each resident. (42 CFR 483.60)
    • Be administered in a manner that enables it [the nursing home] to use its resources effectively and efficiently. (42 CFR 483.75)
    • Maintain accurate, complete, and easily accessible clinical records on each resident . (42 CFR 483.75)
    http://www.cms.gov/Regulations-and-G.../som107c07.pdf
  5. by   Catzilla
    The vagueness of this:

    "Have sufficient nursing staff. (42 CFR 483.30)"

    Admin. can say staff is "sufficient", just "work faster, smarter".
    That is, until something terrible happens as a result of under-staffing.
  6. by   chuckster
    While this must be a tough situation for you as well as the others working in the institution, I suspect that the patient-nurse ratios (and work loads) you describe are within most state's regs. They would be in my home state of PA, which I think allows something like one RN for upwards of 100 patients in LTC in the evenings.

    Sorry to suggest this but your best bet may be to find a postion elsewhere.
  7. by   Maremma
    Indeed yes I have am back to work and the aid that I asked to watch the patient was ultimately found to be the one guilty of tying her fast to her chair and is terminated.
    Yes I understand that patient ratios for LTC are what they are and although it can get busy and problems do come up when I work down a strictly long term care hall I can still manage it.
    I am strongly questioning the sanity of using the same ratio though down my permanent hall. These people are NOT all long term care. The brunt of them are "rehab" patients coming straight out the hospitals. Many are not "just rehab" people from surgeries or car accidents ect. They are sending me unstable psych patients, or dementia patients that ALSO have broken bones PICC's nephrostomy tubes,peritoneal drains catheters, IV's, wound vacs, G--tubes etc. These people require FAR more care than a "long term resident" or a "normal" rehab patient that ONLY has the "car accident" or "physical limitations" that require rehab.
    Imagine having MULTIPLE behavioral patients pulling out their PICC lines or IV's or yanking on their G-tubes, trying to stack furniture against their door to keep you out, beating the crap out of you because they are hallucinating that something is attacking them etc. Try bladder scanning and cathing a patient that was heavily drugged in the hospital then they cut them off from all those drugs and send them your way just in time for the crap to be wearing off and the poor guy has 1000 cc of urine stuck in his bladder! At the same time keep the patient in the next bed calm as they go off the deep end because their room mate is trying to strangle the nurse and they themselves are suffering a panic disorder along with their other physical issue that brought them there. yeah daily ordeals like this in the hall I work in right now. It never fails either, the domino effect happens every time one psych patient goes downhill, the rest follow.
    Indeed it is in my best interest to look for work elsewhere and I am trying but I still don't have my first full year experience yet and so it is making if rougher to get hired anywhere else yet. Still even if I do find another job that still leaves the problem for these poor patients and the next nurse that is put down there permanently. God help them. On my days off the nurse's that have to work my hall dread it and go home crying. One outright quit. Another went to overnights to avoid having to work the 3-11 down this hall. I am hoping that there is a lower ratio for nurse AND aid to patient ratio for "rehab" patients that the facility just isn't recognizing down that hall yet. Particularly PSYCH/rehab patients. it wouldn't be the first thing they did not recognize until an outside source told them they can't be doing something they are doing.
  8. by   wendowen
    First I want to say .. I am sorry, I have worked SNF rehab and understand the messy side of it, I have also worked hospital recently and understand that it is not the hospital that kicks people out, it is the goverment regulations that people only have so many DRGS days for their dignosis, if they use up all there hospital days then bye bye its off to snf to recouperate... yes people are sicker today then they were 40 years ago, becuase of the advancements in health care.. nursing homes are turning to rehab to make a dollar becuase that is where the money is.. dementia pts dont pay for the light bill.. if you have to work snf rehab work nights if you can until you can find a better job.. I used to be an LPN worked snf and hated it, went back and got my RN worked hospital and am now doing hospice.. there are always better jobs out there.. keep your head up.. and apply apply apply... the right job will to you... hang in there..
  9. by   Esme12
    Quote from Maremma
    Indeed it is in my best interest to look for work elsewhere and I am trying but I still don't have my first full year experience yet and so it is making if rougher to get hired anywhere else yet. Still even if I do find another job that still leaves the problem for these poor patients and the next nurse that is put down there permanently. God help them. On my days off the nurse's that have to work my hall dread it and go home crying. One outright quit. Another went to overnights to avoid having to work the 3-11 down this hall. I am hoping that there is a lower ratio for nurse AND aid to patient ratio for "rehab" patients that the facility just isn't recognizing down that hall yet. Particularly PSYCH/rehab patients. it wouldn't be the first thing they did not recognize until an outside source told them they can't be doing something they are doing.
    The regulations for behavioral restraint are on set of rules and a completely different set of regulations for restraint due to medical device restraint.

    Staffing? Unfortunately to some degree is highly variable...but there are different regulations for a LTC patient and a Rehab patient AND there is a difference in reimbursement from the government for this level of care....look for another position but you can always report them. Call the ombudsman of you state. Use the "report" tags on the CMS/Joint Commission site. Call the board of health with an anonymous complaint.

    I wish you the best...
  10. by   Maremma
    Ahhh okay so maybe I can also begin to understand some of the other "crazy" stuff that I keep see happening when patients come in from the hospitals. More than once these people have been "chemically restrained" at the hospital. Heavy medications were being administered that kept them "knocked out" so to speak due to their behaviors while there. This is perfectly legal, accepted practice and routine correct?

    Once they leave there though and come to us they are just cut off cold turkey.They are simply "swapped" to the regs of a LTC facility which required we do NOT chemically restrain unless ABSOLUTELY necessary and ONLY after all other methods have failed. (Usually meaning someone has to get hurt before they will even consider small doses of any medication to calm them)

    So not only are these people completely off their normal regular meds that their personal Dr worked years to stabilize them on. (This has happened over and over and over when they land in the hospital) They are then heavily sedated with other heavier drugs to control the behaviors they then display at the hospital,due to being stripped of the meds they had been on for years before hand. Frequently these people also the come to me with horrible pressure ulcers some requiring wound vacs that were acquired while in the hospital. It doesn't take a rocket scientist to figure out that these people were so heavily medicated they couldn't move at all to have developed such terrible ulcers. (and that they most likely were not turned and repositioned often enough)Once the drugs wear off these people are ALL OVER the place, VERY capable of far more than repositioning themselves is putting it nicely. Can anyone explain the rationale to why we do this with psych patients rather than keep administering the meds they were on before they landed in the hospital? I am beyond dumbfounded every time I see this in their charts.

    Then when it is time to leave the hospital we STILL do not put them back on their regular routine meds and cut them off cold turkey from the heavier things they were taking in the hospital and have to not only have the patient displaying all the S/S of their original mental health disorder we now have them in withdrawal to boot. My head spins at the seeming lunacy of this practice. WHY do we do that? How in the world do we justify this?

    Is this how ALL hospitals and nursing homes do things? It amazes me that there are not all kinds of law suites against the hospital and us from than families of these patients. More than once I have heard from the patients family that their loved one was stable and "doing well" with their psychiatric disorder and then everything went downhill at the hospital. The families are not stupid, they know full well the hospital took their loved one off the meds they were on. They also met brick walls when begging the hospital to give them their meds they were receiving at home. O course they only ever get the nurse who can do nothing but explain that the Dr has to order the meds we cannot just give patients meds at family request. So then they are holding out hope that "as soon as" they get out of there and to our facility their loved one is going to get "put back on track". Alas no so luck here either! Then I have very angry family members to try to deal with too. I just can't get it. "if it ain't broke don't fix it" seems like a real good idea when a psch patient comes along that also has an acute physical problem.
  11. by   ncat
    any facility u work in should watch out for satff and pt populations. u may have to find another job in another faclility to save your own sanity and skills. we all develop a short way of doing things, but sometimes with that scenarion-how can u do this safely. also-i am sure other faclitities in your area have heard about this facility as word travels fast in the medical world. u can always change jobs citing there is a professional dis-agreement on philosophy of care. remember-u must watch out for your performance and gaurd your lisc.-keep your own mal-practice insurance and practice safe.
  12. by   BearishBob
    Can you go back to school and get your RN? You would have more options as an RN. Like quitting the job you have now.

    The only state that has state mandated nurse to patient ratios is California. However, its not all sunshine and roses there. The hospitals have just fired all the ancillary staff to make up for it.
  13. by   Maremma
    Well isn't that so nice of California health care facilities! Well I suppose they are going to learn their lessons the hard way too. They have eliminated all the LPN's at the hospitals around here. It is really sad all the way around. The patients are receiving far less care now and many more serious errors are happening to them because of this decision.
    The facility I am working at has some real long term nurse's. They tell me "how it used to be back in the day". They said quite shortly after the hospitals did what they did we began receiving more and more patients in worse and worse condition coming directly from them. Including these deep to the bone infected pressure ulcers that require wound vac and IV antibiotics. They said when the LPN's were still in staff with the RN's they NEVER received patients from there in such horrible conditions.
    RN's can only do so many jobs at once too. it is so sad that the greed of these places is creating such horrible outcomes for all concerned.
    The original plan was to get my LPN while I worked as a CNA then work as an LPN while I continued on in school to get an RN. I have health issues though that I will need to be able to get back under control before I even dare to try juggling it all again.Going from early morning til late night seven days a week for a year and half straight did a number on me that I still have not fully recovered from. Of course the paying for it also plays a huge factor in going back too. I would love to keep continuing my education, the heart is willing, the body and finances not so much.
  14. by   Epic_RN
    Quote from BearishBob
    Can you go back to school and get your RN? You would have more options as an RN. Like quitting the job you have now.

    The only state that has state mandated nurse to patient ratios is California. However, its not all sunshine and roses there. The hospitals have just fired all the ancillary staff to make up for it.
    Not sure what you're referring to, my CA hospital has not let any ancillary staff go.....

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