A.M. care in a ltcf

racing-mom4, BSN, RN · Mar 23, 2008

I have only been on allnurses.com for about 2months now and i have seen so many post on the trouble in LTC. I keep saying changes need to happen from the top down and it starts with Staffing-yet just because we say that it is not going to happen.

I dont know how many LTC DONs are on this board.

What can we as a large group of educated care givers do? Really--we cant walk out---we cant refuse to care for 30 some residents. So what are our options? We can chose not to work for LTC centers who are understaffed, but guess what, someone else will. So they will stay open.

Unfortunately I dont have the solution. But I do know if we dont already each of us at some point will have a loved one in a LTC home and 20 years from now and if things dont change we will still be complaining about the same conditions.

Obviously staffs complaints to mgmt are not working, $$ talks in all industries and if paying customers aka patients families start complaining---then maybe--just maybe some changes will be made.

I wish us all luck, I hope sometime during my career I will see changes in LTC. I hope the changes happen before I find myself or my husband in need of their services....

**Elektra6, ASN, BSN, RN** · Mar 24, 2008

The long-time CNAs tell me that in the past they had lots of time to spend with residents. They would paint nails, do hair, lots of extras. Now due to staffing and more demands, they can barely do the minimum. Sad, sad, sad......

noc4senuf · Mar 24, 2008

Back in the 70's when I was a CNA, we had from the time we got to work at 6:45A until noon to get our 10 residents out of bed, showered, dressed, etc. I usedto set my ladies' hair in rollers after the showers and they would be beautiful by lunch.

Now because the gov't states it's a dignity issue, we need to have them fully dressed to come to the dining room. Also, unless they are ill, they don't eat in their rooms.

I noticed decades ago that it had become an assembly line to get the residents taken care of "properly" according to regs. It is this mentality and the ongoing cost vs. reimbursement that we have ended up with the system that we have today.

I as a DON try very hard to staff for acquity and not just numbers. I also have a CEO I have to answer to and justify my actions. With the new QIS coming down the line, I believe we will see more staffing being added to facilities as it will be based more on resident/ family interviews than just solely on what is seen and read.

racing-mom4, BSN, RN · Mar 24, 2008

Back in the 70's when I was a CNA, we had from the time we got to work at 6:45A until noon to get our 10 residents out of bed, showered, dressed, etc. I usedto set my ladies' hair in rollers after the showers and they would be beautiful by lunch.
Now because the gov't states it's a dignity issue, we need to have them fully dressed to come to the dining room. Also, unless they are ill, they don't eat in their rooms.
I noticed decades ago that it had become an assembly line to get the residents taken care of "properly" according to regs. It is this mentality and the ongoing cost vs. reimbursement that we have ended up with the system that we have today.
I as a DON try very hard to staff for acquity and not just numbers. I also have a CEO I have to answer to and justify my actions. With the new QIS coming down the line, I believe we will see more staffing being added to facilities as it will be based more on resident/ family interviews than just solely on what is seen and read.

Excuse my ignorance but I dont know what QIS is. I do not work in a LTC facility, I did though work in one as a CNA while in school. I am very passionate about changing and improving conditions, but I feel as the mountain is just too big.

I would leave the LTC depressed and in tears many of mornings ( I worked 3rd shift---I had 10 residents to get up and dressed before I could leave at 6:45am!!!) I now chose to work in an ICU where I feel like I am making a difference and am listened too.

I have two grandmothers in LTC homes and it just breaks my heart as though I know they are being cared for by kind people the staff is just so overworked they dont have the time to treat my grandmothers the way I wish they would be treated. I have seen my grandmothers in the same clothes for days on end. I know exactly how that happens, their shirt may not be "dirty" so to save on laundry it is re-hung in the closet, since the shirt is large and easy to get on, it is one of the 1st ones grabbed in the morning. As the person who gets her in her PJs is not the same person who gets her in her day clothes. Their hair is not brushed and their dentures are not in. Last time I visited my grandmother, she was in tears and so upset because a "man" had to give her a shower. This is a woman whom I have never even seen her knees. She is very modest.

So the main question is---what can we as registered nurses do? How do we even begin to make a dent in the problems??

If families call in, does that matter??? or does that just get some un-lucky stressed out nurse in trouble?

noc4senuf · Mar 24, 2008

Sorry, the QIS is the Quality Indicator Survey. Not all states are knowledgeable of it as it was first started in only 5 states and is now just beginning to expand. MN is just in the beginning phases. Instead of the surveyors coming in and immediately going into observation mode and reviewing charts, they are now to interview X number of residents whether they are cognizant or not. THey also will interview family members. Based on their findings, they will then investigate and review items in charts based on the answers received.

Thus, if residents/families complain about the ADL's... this is what they look at, if it is the food... that's what they look at. So, it comes down to satisfaction. If the residents/families are not satisfied, then I believe we are looking at more staff to accomodate and make them satisfied.

How do we change what is already happening? I think it all goes right back up the ladder to management. It has to be proven that more help is needed to make the residents feel like human beings. Luckily, once i prove a point, I am allowed to add the staff i need to make the ratios workable.

As for the families who speak up, i encourage it. But, I do say there has to be realistic goals put forht by the families. There are those that are so unrealistic, that they take away from other residents that do need something more than their mom/dad.

Chaya, ASN, RN · Mar 24, 2008

I really think more public needs to be aware of how some facilities run,at times.Family members seem to be catching on because my staff has been telling them.When a family member asks for something and the cna is too busy at the moment,they have said,"I will be with you when I can,we are short".Boy management would kill me if they knew I knew they say this and dont repremand them for it.I used to tell them they shouldnt tell the families this,but now I dont say a word!!!!!!!!!

It's not just some facilities, it's pretty widespread from what I've seen. This is what happens when the ONLY priority is the bottem line. I refuse to cover for management's lack of staffing. It's not like the CNA's and nurses are sitting with their feet up reading a magazine. Staffing is such that the CNA can complete AM care at a dead run with no frills and no time to spare. One resident/ patient who has an "accident" is all it takes to set you back. I think families need to know that staff would LOVE to be able to do Granny's hair and pamper her a little but they feel lucky if they can get through dressing and basic hygeine/ mouthcare on their whole group in the time allotted.

racing-mom4, BSN, RN · Mar 24, 2008

The QIS sounds like a wonderful much needed program.

I find it so frustrating to see so many posts on here about the terrible conditions of LTC, and to see with my own eyes how frazzled and burnt out the LTC staff seem to be.

I have what I think are wonderful ideas to at least slightly improve, but unless I am a key member of mgmt (which I am not--I am not even an employee) my ideas dont get heard.

Since you are a DON at a LTC home I will share 1 idea with you and you tell me if it would work or not...

Meal time---at least for lunch and dinner, how about every member of the facility, including housekeeping to front office to mgmt help with meals. Help by either gathering the residents out of thier room to take them to the dining hall to help with feeding the feeders ( when I was a CNA I had to feed 6 residents at once--you know how cold the food got and how soon they lost interest in feeding??) I dont think you need a lic to feed someone. OK maybe someone who had a stroke, but an ahlz pt, I think anyone can feed. **How about a hot-cold salad bar for the walkie-talkie residents, that way they can pick and chose their own food--I think they would eat more if they could have a choice.

What about extending breakfast--that way you dont have to get all 100 or so residents up and dressed by 0800. You could have an early and late breakfast. That would allow more time to get the late breakfast folks ready--thus allowing more time to get the early breakfast folks up, because your stretching your time . Maybe who ever got a shower that day could be on the late breakfast list.

I know I said I would just give one idea, but here is another---why not have the housekeeping staff make the beds??? It may only take 1min for the CNA to make the bed, but you figure she has 10 patients to get ready, that is 10 minutes. 10 minutes in LTC is a luxury.

I really wish there was something that I could do to make even a small change to get the ball rolling. I just hate to see the assembly line system LTC home run. I am not blaming the LTC facility, they must do X amount of work in X amount of time, and assembly lines work...but all it takes is one person to require an extra 2 minutes of care and the snow ball effect takes place, and that 2 min turns into 20 which turns into 40 etc etc etc, someone is paying the price.

Lovely_RN, MSN · Mar 24, 2008

It really burns me up that we are not supposed to tell the families that we are short staffed! It's not like they can't see that with their own eyes anyway. I have a CNA on my floor who has been on the job for more than 20 years. She was telling me last night that when she started out we used to have 1 RN, 1 LPN, and 4 CNAs on evening shift for 40 residents. Now we have 1 LPN and 3 CNAs for the same amount of residents. Also a lot of the medications the residents are on didn't exist 20 years ago and the residents are a lot sicker now.

I think the families need to know what is really going on in LTC. It really burns me up to see all of these commercials about LTC neglect and abuse. The finger is always being pointed at us staff for not doing what we are supposed to do when the finger should be pointed at the money grubbing jerks who own these facilities and refuse to pay for enough staff or supplies.

racing-mom4, BSN, RN · Mar 24, 2008

I totally agree---the supply thing. When I worked in LTC 3rd shift, one night we ran out of washcloths, we had already had the wet wipes/baby wipes taken away from us, so we were required to use a washcloth to wipe pts bottoms.

Well no washclothes, so I suggested we cut up the bath blankets and use those.

2 days later myself and the Nurse who agreed to cut up the bath blanket were written up for destruction of property!!!!

We were told if we ever ran out of washcloths again to use paper towels or Toilet paper. We were then told if residents didnt hoard linens in their room we would not have run into this problem...so part of our new nightly routine was to search pts rooms for stashes of wash clothes/towels and sheets.

There were plenty of nights that we were short on linnens, so we would skip a bed check. Because god forbid 1st shift walks in to see a pt in a wet bed--or worse yet a family member finds them wet. So we had to skip the 3am bed check and just change them at 5 or 6am.

noc4senuf · Mar 24, 2008

I used to work in a facility where when due to snowstorms, unforseen problems, etc. everyone in th place was trained to feed, from the NHA down to maintenance... that was in WI. Depending on which state you live in, you may or may not be able to have others assist you with feeding (more regs).

The alternative you suggested to eating at different times is taking place all over the U.S., it is part of the "culture change" movement. Instead of early morning breakfast, a brunch is set up mid-morning, a large meal in the middle of the afternoon, and a lighter snack in the evening. There are also snacks in between. Many facilities have gone to this type of dining. The problem I have heard about is finding a time to take blood sugars and administer insulin. Our Medical director has asked us not to go to this format.

If we need assistance in our facility, we page for assistacne and help coems running. No one ever feeds more than two residents at a time.

I have worked in facilities where housekeeping makes the beds.... it's just what works in one doesn't always work in another.

I have been in long term care for 30 years (not all as a nurse). At various times, I have had my own grandma, step-grandma, and grandma -in-law to care for. I treated them just as another resident on my floor while working... no one gets better treatment than another. But, I do know where families are coming from.

Why do I stay in the LTC area? Because i love working with the elderly and I do whatever i can to make their life more meaningful.

racing-mom4, BSN, RN · Mar 24, 2008

Why do I stay in the LTC area? Because i love working with the elderly and I do whatever i can to make their life more meaningful.

There needs to be more people like you. The work is so physically/mentally demanding in a LTCF and the respect level is so low that I think they lose good nurses and CNAs.

I have thought before about going into mgmt at a LTCF because I really am passionate about improving the conditions. It just seems as if the mountain is so big. Maybe some day I will find myself as a staff member of LTC.

Thanks to all you do.:yeah:I think there is a special place in heaven for LTC staff.