Advice Please! Skilled Nursing to Assisted Living

[Jesshayesatx, LPN, LVN]

Hello! Thanks for taking the time to read this! I have 2.5 years experience in a skilled nursing facility doing treatments, wound care, IVs, meds, trachs you name it and I have med surg experience. 

I recently had a job offer close to my house at an assisted living memory care facility. The hours are perfect 6a-2pm M-F but I’m not sure what to expect. I’m a little surprised they don’t have a DON or even a ADON. They said there will be one nurse per shift and no nurses overnight just CNAs watching 80 residents. I do get two meds aides during the day but even my boss who is the nursing director is an LVN so no RN on site. I understand most residents are stable but is my license in jeopardy?

I like to think my assessment skills are pretty good but I was always taught to  protect your license & never work as the only nurse. Any advice or thoughts? 

[Firewood, RN]

Hello,

I've never worked in a skilled nursing facility, everything I've done has been hospital. But 1 nurse on days and none on nights for 80 pts seems dangerous. Sounds like you would be responsible if something bad happens. I wouldn't do it, sounds sketchy to me...

[Jesshayesatx, LPN, LVN]

4 minutes ago, Firewood said:

Hello,

I've never worked in a skilled nursing facility, everything I've done has been hospital. But 1 nurse on days and none on nights for 80 pts seems dangerous. Sounds like you would be responsible if something bad happens. I wouldn't do it, sounds sketchy to me...

My thoughts exactly! It was worrisome when at my interview they were just like “These aren’t like skilled patients they are all pretty stable.” Yeah but patient conditions change all the time. Thanks for commenting!  

[Firewood, RN]

No problem!

Happy to add my 2 cents for what it's worth...you have to protect yourself and your license!

[S98]

Hello,

I’m a new grad so I don’t really have much experience but the place that I applied to have a 1:15 to 1:20 nurse to patient ratio so that sounds a bit concerning. And if anything goes wrong, it might cost you your license. May I ask how much they are offering to you?

[vampiregirl, BSN, RN]

Hi!

My perspective is coming from a hospice nurse (and some home care experience) who interacts with ALFs.

I would encourage you to look up your state regulations for ALFs to see what they are. I'm guessing there is a lot of variation between states.

Another recommendation would be to inquire about on call requirements for this position. In my state, if an ALF has less than a certain number of residents then a nurse is not required for night shift. But they must have one on call at all times.

I've interacted with a few ALF facilities have very limited scopes of practice for their nurses - calling 911 is facility procedure for anything. The nurses aren't permitted to assess or provide treatment aside from CPR until EMS arrives. If a patient falls, they are not permitted to assist them up even if the patient is denying injury and must wait until EMS arrives to assess/ assist the patient. If a patient has a wound, catheter or any other treatment that the patient is not 100% able to perform independently then the patient must be receiving home health care services or have an outpatient provider. 

I've also interacted with some ALFs where the nurses are permitted to perform some nursing interventions with orders. I've seen this more often in larger ALFs or one connected with a SNF. 

Some of the nurses I talked to at good ALFs have been there for years and love their role as ALF nurse. They find the personal relationships fulfilling, enjoy coordinating wellness activities and tell me there's a lot less documentation involved. They enjoy the autonomy of the role and most have told me it's lower stress. I think the quality of the ALF management/ leadership and the patient population also makes a huge difference. Other ALF nurses I've talked to miss the higher acuity and find the facility scope of practice limitations frustrating.

[neuron]

Sounds like an unstable work environment. They are stable patients, but when 1 fall turns into 2, and 2 wounds to 3, a patient turns into a  hospice patient, the work adds up. You still have to admit, call MDs, ensure code status and send via 911. 

[DonnaMalagoli]

I previously administrated an assisted living facility x 12 years. In assisted living the clients are supposed to know their medications, may need some assist with ADLs, should be actively mobile. I only accepted clients that were appropriate for this type of setting. I was fortunate that the owners were not pushing a  "fill the beds at any cost" policy.  Not true in most facilities today. There are patients in assisted living that now that need more than a little assist. Many  are confused and  are definitely more nursing home that personal care. Unfortunately, most personal care/assisted living facilities operate on minimal staff ;and  personal care aides are not CNAs.   If as a nurse you are taking a position in an assisted living facility, educate yourself as to how much care the residents do require, just what your responsibilities will be as the nurse in this area. If a CNA calls off, will you have to fill in.  Is the facility all on one floor or will you have to go between floors.  If it is a large multifloor facility, you may be run ragged.  Be smart, ask questions before saying yes to a position.  The pay in assisted living is also not the greatest even if it is a facility that is private pay.  I enjoyed working in assisted living when I did but got out when things started changing and moved on to another field of nursing. 

[CrunchRN, ADN, RN]

I have my MIL at a wonderful ALF with a memory care unit embedded. They have fully independent residents to those that need assist with meds and toileting and more. My MIL requires assist with everything, but still gets to enjoy her apartment.  There is an LPN DON who works M-F. There is an assistant DON LPN who work Tues - Sat day shift. They run things. Then there are made aides and "personal assistants" who are there 24/7. If something comes up they call one of the nurses (at night etc). The nurses love it their and the staff are pretty stable. They do a really great job in my opinion.

[No Stars In My Eyes]

Somewhere I briefly worked did not allow an LPN to work 'charge' unless there was an RN 'on-site' somewhere in the building. 

[VivaLasViejas, ASN, RN]

I was a DNS in assisted living for 7 years, and loved it until the administration started admitting residents who needed memory care, who needed 2-person assist with all ADLs except feeding, who had serious wounds that required daily nursing care…in other words, they should have gone to a nursing home! When I started ALF nursing, the vast majority of my residents were walkie-talkies who needed a little help with their meds, bathing and/or dressing. When I left, it had become all about the Benjamins; anyone who wanted to live in our facility had to be allowed admission and I had to figure out how to take care of them, even though I no longer had any say in the matter. 
 

Needless to say, I didn’t appreciate being treated like a mushroom (you know, kept in the dark and fed BS) and I began to fear for my license. There is NO WAY I would work in this setting again even if I were still a practicing nurse; from what I’ve heard it’s worse now than it ever was when I left. No thank you!

[kbrn2002, ADN, RN]

It might be OK if the residents truly are independent to the level appropriate for the setting and all are medically stable. I think that is rarely the case however.  

You said you are coming from a SNF, did your facility ever admit residents from assisted living? If so were they usually in a condition that caused you to think "how on earth did they manage them at an assisted living so long??" If so, there's your answer.