Appalled at LTC standards of nursing care

Chin up · Mar 27, 2011

As you stated, you have not worked in LTC. The place you are describing should be closed down. No, it is not the norm. I would not work there. In my state, if what you say is true, it would be shut down. LTC facilities are residents home and infection control is very strict. We are also paid by assessment and documentation, so that area is very strict. SBAR is more important to us, for payment sake. So, the nurses, RN and LPN Know their business or won't have a job. You notice I qualified everything by money, this is what rules LTC, and what is pushed to death. You unfortunately are in a h*ll hole, so get out.

nightengalegoddess · Mar 27, 2011

Good advice. So glad to hear this is not the norm. Think I will do my orientation, do the work the way I know it should be done, and take my check and run. Thank you!!

sasha2lady · Mar 27, 2011

I'm an lpn in ltc and I totally understand your pov but not all are like that. But one thing you didn't mention was the comparison between workloads in a hospital versus ltc. In a hospital a single nurse would never have the load we do in ltc patient wise. I have 36 just by myself! 12 + are rehabs (med A) with every condition you can think of and my remaining 24 are skilled total cares with feeding tubes etc. In my 12 yrs in ltc I can't recall a single hospital nurse who stayed except in mgmt. It's a different world in ltc but the same principles for infection control etc should be in place.

Sounds like you got stuck in one of the bad ones.

Also in ltc the staffing is usually worse-more call outs and unreliable staff. Easier to burnout and get frustrated too .

Chin up · Mar 27, 2011

I'm an lpn in ltc and I totally understand your pov but not all are like that. But one thing you didn't mention was the comparison between workloads in a hospital versus ltc. In a hospital a single nurse would never have the load we do in ltc patient wise. I have 36 just by myself! 12 + are rehabs (med A) with every condition you can think of and my remaining 24 are skilled total cares with feeding tubes etc. In my 12 yrs in ltc I can't recall a single hospital nurse who stayed except in mgmt. It's a different world in ltc but the same principles for infection control etc should be in place.
Sounds like you got stuck in one of the bad ones.
Also in ltc the staffing is usually worse-more call outs and unreliable staff. Easier to burnout and get frustrated too .

Dag Sasha, even for LTC your work load is much tooooo much!! Even for a night shift, wow. I wouldn't subject myself to that for too long. You are probably burnt out now...just don't realize it. Peace girl!

Chin up · Mar 27, 2011

Good advice. So glad to hear this is not the norm. Think I will do my orientation, do the work the way I know it should be done, and take my check and run. Thank you!!

I am actually glad you said you would stay and do things, the right way. LTC is in desperate need of strong RN's. You can be the change, that facility needs. Good luck!

Chin up · Mar 27, 2011

Just a feeling...Staff development coordinator, anyone?

Nascar nurse, ASN, RN · Mar 27, 2011

Please remember, LTC and acute care are not the same beast. LTC facilities are the residents home. The routine staff get to know these residents very well. You will want to watch "picking on" LPN's on this board or you may get eaten alive!

1. Infection control. You should have gloves that fit and microbial wipes available. You should not expect to see the same infection control practices from the hospital. Again, this is their home. In my facility we use contact precautions for MRSA. If the infection is in a wound, as an example, the wound is covered well and no one is picking at it so they are free. Now we do try to cohort residents with the same infection. In a hospital, this same resident may well be isolated. If we isolated every person, 50% of our facility would be on "lock down" at any given time. To all the acute care nurses ready to attack, let me assure you that we track all new infections from month to month....it is very very rare that we ever have a nosocomial cross contamination event.

2. Dr rounds. When the Dr. comes in to visit every 30 days, it's not about just a physical assessment. It's an assessment of their condition over the last 30 days....how are they eating, have they lost weight, memory changes, mobility changes, etc. But, on the other hand, I have also seen some very poor assessment skills in LTC (by both LPN's AND RN's). It blows my mind when any nurse can come tell me that they think so and so has pneumonia but there is no documented lung sounds - yikes.

3. Assessment skills. Residents that have just been discharged from hospital should have a nursing assessment done at least every shift for at least 72 hours. Most residents after the 72 hours, will have an assessment done at least daily while on medicare A. Most residents after that period of time are "stable" and have no need for a routine nursing assessment.

4. Lab retrieval. Ours are drawn thru the local hospital per our contract. If they miss sending a result back to us, I just pick up the phone and ask them to fax it over. Someone should be accountable to see that you get back all lab reports in a timely manner.

5. Documentation. I'm not sure what you are expecting to see for documentation so I am not sure how to help you on this one. All i do know is that we document everything in a hundred different places - ad nausem.

6. Nip picking enviornment. Haha! We got that too - it's just a different beast!

You may be in a bad facility or maybe you are just having a hard time coping with a new way of doing things?? Best of luck.

nightengalegoddess · Mar 27, 2011

Thanks, you guys. I guess I just wouldn't dream of doing a complex dressing change without charting every detail of character of wound...for one thing. I am also wondering, when you see a need for intervention...aka s and s...are you supposed to call the doc like in the hospital for a med or test??? The LPNs seem to shun this? Also, what about x-rays after a fall? This is not routine there either? I noticed that as well, how can you think someone has pneumonia without assessing lung sounds or charting s and s??( as nascar said)....As I wrote, I will only finish my orientation and nothing more, I think. It could be a lot of trouble for me to bring up all the facilitiy's faults...I am just going to take the 12 patient load and do it right during my orientation. And then I probably will not stay unless I see something better developing there.

Nascar nurse, ASN, RN · Mar 27, 2011

Thanks, you guys. I guess I just wouldn't dream of doing a complex dressing change without charting every detail of character of wound...for one thing. I am also wondering, when you see a need for intervention...aka s and s...are you supposed to call the doc like in the hospital for a med or test??? The LPNs seem to shun this? Also, what about x-rays after a fall? This is not routine there either? I noticed that as well, how can you think someone has pneumonia without assessing lung sounds or charting s and s??( as nascar said)....As I wrote, I will only finish my orientation and nothing more, I think. It could be a lot of trouble for me to bring up all the facilitiy's faults...I am just going to take the 12 patient load and do it right during my orientation. And then I probably will not stay unless I see something better developing there.

We do complete wound documentation once weekly unless there has been a change. Yes, you should call the Dr. if there is something new to report and you need a new med/tx. We don't routinely do X-rays after a fall...if you fall down at home do you go get X-rayed -- or do you only go if you have a suspected injury? I can't help but notice that "LPN" thing again. I can just tell you, there are some bad LPN's out there...but I've also seen some really scary RN's too. In LTC it is the nursing team. If you want to survive in LTC you need to drop this LPN thing.

Why in the world would you stick around for orientation with no expectation of doing the job? That is unfair to the staff taking the time to teach you, it is an unfair intrusion into the residents home, it is unfair that the facility does not know that they will not have this open position filled and it is unfair to some other nurse out there that is desperately seeking a job.

Chin up · Mar 27, 2011

Thanks, you guys. I guess I just wouldn't dream of doing a complex dressing change without charting every detail of character of wound...for one thing. I am also wondering, when you see a need for intervention...aka s and s...are you supposed to call the doc like in the hospital for a med or test??? The LPNs seem to shun this? Also, what about x-rays after a fall? This is not routine there either? I noticed that as well, how can you think someone has pneumonia without assessing lung sounds or charting s and s??( as nascar said)....As I wrote, I will only finish my orientation and nothing more, I think. It could be a lot of trouble for me to bring up all the facilitiy's faults...I am just going to take the 12 patient load and do it right during my orientation. And then I probably will not stay unless I see something better developing there.

As an MMQ/MDS coordinator, I expect every detail of character of wound. If not charted we don't get paid. When you see a need for intervention, of course, you need to act. Some nurses DO, think nursing is passing meds. They don't last long in this business. I don't think that is what NASCAR was stating. She was giving an overview of what we do in LTC. But nursing is still nursing. We have to follow the same standards and expectations. We should be checking lung sounds, getting cxr as needed. Yes, we are to call the MD or send them out when warranted. What you are describing is neglect and poor practice. That is not an LPN function and those who are not following policy, need followup training, or dismissal. In my facility, I encourage staff to come to me or staff development when they witness poor practice. This is Not to get nurses and or CNA's in trouble, but for training. If a nurse or CNA feels the need for more training, they can request anytime. Patient satey is priority and some of the issues you mentioned, can't be tolerated. Peace!

pedsrnjc · Mar 27, 2011

Kudos to LTC nurses, it stinks. Nascar nurse explained things very well. As far as the falls go, you have to learn how to assess whether there is a fracture or not. Your assessment skills will probably strengthen in LTC, as often these poor people are warehoused waiting to die, which is often the only way to discharge, and many MD's don't really care about LTC residents.

When I worked LTC, even when calling a doc about a fall, their first question was always code status, which often even affected their treatment. For instance, if the resident fell and neuro assessment wasn't right, MD would ask for code status and if a full code, send to ER, if DNR, keep on monitoring. I learned to always contact the family first and find out what they wanted even before calling the MD. Of course, you have to use your head, feel free to call an ambulance and then get an order to send to ER, just make sure it is really called for. A not uncommon call for me, "Good evening Doctor, thanks for calling back. So and so fell off his bed and hit a garbage can with his ribs and was in respiratory distress with tracheal deviation, he is now in ER, facility policy states we must have an MD order to send to ER? May we please have an order?"(yes this happened)

As far as pneumonia goes, some of these people can develop pneumonia in a matter of hours, seriously.

I couldn't do LTC anymore, I don't believe in the care model. In this bad economy, I quit my job with no safety net and ended up getting hired in pediatric home care, which I believe in. It has gone very well.

Also, be wary of any place that says "In Christ's love everyone is someone", very bad employment practices there. Unionized LTC facilities seem to have better nurse to patient ratios and overall better care. Good luck to you.