Appalled at LTC standards of nursing care

NurseLoveJoy88, ASN, RN · Mar 27, 2011

Hi. I have never worked in an LTC before. Just hospital acute care. Orienting, I noticed there is not assessment going on, there is not proper documentation going on, nor infection control. There are not even readily used anti-microbial wipes nor proper sized gloves in the rooms. Patients have MRSA and there are not infection control measures being enacted. The system is completely askew, and the charts are completely disorganized. There is not system for lab retrieval, and I wonder what the clerk is actually doing? When the physicians come, it seems like the LPNs don't know what to discuss with them re: SBAR. How can you discourse about the patient if you have not even physically assessed! I am an RN. Is this the difference? Are LPNs educated to such a less degree about the thouroughness? Or is this place uncommon. Much prefer the nitpicking hospital environment. Please tell me what the heck is going on here?

To answer that question you asked in bold... the answer is no. LPNS are NOT educated to have a less degree to thouroughness. I think each individual nurse should be responsible for his or her actions. Also, at my facility the RN is actually responsible for setting the assessment guidelines , infection control, and proper documentation so thus maybe the RN may have contributed to this as well.

JenniferSews · Mar 28, 2011

Oy. No, with 30 patients, it's just not possible to do a full head to toe assessment every day. Not that we aren't still competent and caring nurses. Just that in 8 hrs it's flat out not possible to pass 30 people their meds AND do full assessments on each. In theory these patients are stable (hence they are in LTC instead of acute care) and assessments are done on skin once a week and whenever there is a change in condition.

There is a difference between taking care of someone for 3 days out of their entire life and 5 days a week for 10 years of their life. If you know nothing about the patient other than their dx and their admission info from yesterday, of course you need to dig deep, assess the patient and find out everything about them. But if you've taken care of them for 6+ months and you know every nuance of their condition both physically and emotionally a daily assessment is not just overkill, it's an invasion of their privacy. Can you imagine if every day of your life for ten years someone did a full assessment on you twice day? Personally I snuck my assessments in to my med pass and their showers. A quick "can I listen to your lungs before you get up" turns into an assessment of lung and bowel sounds. Then a quick peek at their skin while I helped a CNA get them showered. If you had been taking care of your grandmother for 10 years would you feel the need to do a full head to toe twice day?

Wound dressings are changed at least every shift but only measured once a week. Again, if you're doing the same wound dressing BID for 3 months, what is the point of measuring it every single day? Weekly measurements will show a trend over time, and some elderly patients with many comorbidities can take nearly forever to heal.

I have to agree with CapeCodMermaid. Last time I was in the hospital not one person other than an Md put a stethoscope to my chest or belly. When I was desperate for some pain relief the nurse never responded. I had to wait until the next shift and sat counting the hours in misery until that next nurse showed up 9 hours later. This on a floor with a 1/5 ratio. I wasn't asking much at all. But the care I got was a real eye opener. LTC isn't the only hell.

marthyellen · Mar 28, 2011

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.

Well said. no long term care facility can provide care if there in no team work.

carecrafter · Mar 28, 2011

OMG - I am on here tonite because I am in the same boat. This is NOT the way the LTC place I did clinicals in ran at all.

I have listened for two shifts to a patient on multiple meds who is now unable to swallow and she has been hollering LOUDLY for hours on end. No telling what all withdrawal she is going through let alone pain. It wouldn't even be charted that she hasn't swallowed meds if I hadn't been there. All the nurses seem so jaded, don't like her as a patient and just want her to shut up. BUT, not willing to call the dr - finally nagged one into calling - got an order for haldol and it didn't faze her so now they don't like that I nagged them into "bothering" the MD.

The place is a pigsty - NO PPE at all, no sanitizing wipes - I am getting out ASAP!

Surveyers just left and the place has a LOT of tags -- its BAD. Don't want to put too much detail on here.

I am trying not to act naive, but if I had a family member there, it would take me about 15 minutes to get them out the door - no question.

it seems brutal to me to let a person holler for hours on end, and to allow her to upset residents on two halls from having to listen to it! Am I wrong on that?

wanted to put a "smiley" on here but couldn't find one for APPALLED!

nursingcares, RN · Mar 28, 2011

I'm on my 3rd week of orietation in LTC on an Alzheimer's/Psych locked unit. Although I don't have much hospital experience I, too, was shocked at how little assessment we actually do in LTC. Basically I assess anyone who has any issues (recent falls, ABX, or new s/sx) and we have a list of monthly nursing assessments we do. It's definitely a BIG change. Also, I noticed a lot of things other nurses in my facility do that is totally wrong and I will be doing things the RIGHT way on my shifts. I have also found it very confusing to find out what to do with labs or who is the on-call doc. Everything seems so unorganized on my unit! They just recently switched to computerized charting so even the nurses I'm orienting with don't really know what they are doing as far as charting is concerned. I've also oriented with a couple nurses who I feel so unsafe working with! But I'm not going to leave- I can develop my own way of nursing practice and maybe (just maybe) others will notice and follow suit. If they don't- then it's their license and up to the facility to decide what nurses they hire.

I think the reason the standards are so much lower is because the workload is so heavy and because a lot of nurses see LTC as "less glamorous". I've noticed a lot of nurses I work with either work there just for the money (my facility pays well) or prn to supplement their income. Which isn't necessarily bad because we all need to make a living, but I think I work with one nurse who actually cares about the residents. She was my nurse when I worked there as a CNA and she is an amazing nurse (she's been an LPN for years and years). To me, I think it's selfish to totally discount LTC because it's working with the elderly and "just passing meds". I can't tell you how many times I heard classmates say, "I don't want to just pass meds." when referring to LTC. It is SO much more than that! And when you do things the right way and raise your individual standards of care- it can be extremely humbling and rewarding.

I'm getting a lot of psych experience on the unit I'm on now but not very many skills. I only have one resident who is skilled and she is skilled for behaviors and psych meds/consult. However I can choose to pick up shifts on other units that have tons of skills! For now, I love working with my residents. I find it can be either a very relaxing day or an extremely busy one.

nightengalegoddess · Mar 28, 2011

Wow. Lot's of valuable information. Thank you so much. !!!!

CoffeeRTC, BSN, RN · Mar 28, 2011

I just read the OP and my toes curled. The tilte of your thread should be "Appalled at the standards of nursing care in THIS LTC"

I'm sure the rest of the posters will argue that this place sounds like a dump or that there are no stadards. Since you started off by sayint you've never worked LTC..it could be a bit of a culture shock at first.

How can you not assess a pt? When you walk in their room you start off by listening and looking at them..you can get a good bit of info just by that...orientation, resp status, skin color, check for edema, eye ball the foley cath bag etc...if I'm going in to give meds or a resp tx, I will listen to the lungs and heart...see what I'm saying..just because they are not sayin...."I'm going to do my assessment" and pull down the sheets it doesn't mean you are not assessing.

As far as infection control...every facility has a standard. Gloves and hand washing is the basic. We don't isolate residents for MRSA unless it is in the sputum and they are caughing. We have hand gels pn the walls in the halways. Wipes are also availble for staff to use.

In most LTCs...LPNS run the show. Srsly....very up on the care of the residents and are always communicating with the docs, families etc.

We have a mixture of young, old, short term and a few long term patients. Labs are done as needed. Nurses in LTC can have some degree of autonomy and are able to ask the doc for lab tests...ex..s/s of a uti, chest xray, fall with s/s of pain and needing an xray. Most often when you get a resident who has had pneumonia in the past or gets it every november..the doc is just going to treat it as such and save the money of the xray.

As far as the charting.....how can you not chart? LTC payment is driven by the assessments (MDS) and supporting documentation. As far as charrting on all complex wounds every time you are doing a dressing....The documentation might be found in other places. We have a weekly wound measurement flow sheet that can cover all of this. I used to chart on wounds daily, but it wasn't needed and just double my work. Check your charting p and P. Ask your assessment coordinator/ MDS nurse or staff development what needs to be done. Not everyone will need to be charted on every shift or every day if they are stable LTC patients.

nightengalegoddess · Mar 29, 2011

Thank You, Michelle 126..excellent advice!

nightengalegoddess · Mar 31, 2011

Learning more here...will try to make positive changes for this facility for now....they really do need it....now having read the CMS ratings from last year...(horrifying)..Yes, there are a couple excellent LPNs there, I have found. They have shown me every detail of the process there; SO different than acute hospital care. And I have read a lot online about the state standards and the federal standards so I have a clearer idea of what is really wrong there, and what they need to improve upon. Knowing these standards will help me make valid suggestions within the guidlines which will actually help them achieve something more close to good care. The organizational skills needed for the high patient load are different than those on a med/surg step down type unit...but not undoable...still possible to do a thorough and respectful job correctly....just different guidlines to follow....I thought that all array of lines and interventions for eight paitients in very acute med/surg was harder to manage at first than this will be. NO OFFENSE...not saying SNF is easier! Just different. I am learning and another poster is correct...so many of these patients ARE the forgotten ones, and they are who I am focusing on...maybe I bumped into this one for a reason. The money is also good right now; but that is never enough reason for me to stay anywhere....so guess I will just focus on learning and improving. Thank you for all of your input...very knowledgable and valuable!!!!!!!!!!! ALSO......so sorry your hospital stays were so crummy......our hospital is not this way at all!!!! No matter how many patients I have had, I have always found time to adress each ones' concerns and respond to their input regarding their plans of care....I am not one of THOSE RNs who just treat the patients like objects and/or cattle.......Although, I HAVE seen those and they need to be REPLACED!!!!!!!!thanks again!!!!!!!!

nightengalegoddess · Apr 2, 2011

OK...for anyone still reading.........was on my own today...what they call "working the cart"...and I must say, I CAN provide nursing to my standards here; even though the whole thing is in dissaray.......I actually had a lot of FUN.(Still need to get proper bleach wipes for C-Diff iso......and proper education re: infection control....and back injury saving!)

I saw distictly that the patients were mostly the ones whom left MY hospital , who had no one to change their dressings, run their antibiotics...who were too febile to be alone. Their average stay is two weeks. Although a monumental load of patients, realized that only TWO of my 15 were really possibly at risk for 'any hour' problems like sepsis or cardio/pulm issues.

I "passed the meds".....flipped through all the paper ,paper, paper charting.........bent over the horrendous ergonimicly designed work spaces or lack of (ouch my back).......and had lots of time to therapeuticly communicate in meaningful spiritual fashions with my patients, who really needed the human touch....Also realized that I had never worked with CNAs who tried so hard, cared so much, were as sincere as these.........

The greatest distress was realizing that all they really need for the LPNs who may not be so motivated to advocate...is a freaking filing system!!! A system I could make with some filing cabinets and shelves within one day! Imagine the amount of comfort measures that could be ordered...(not to mention hard labs and meds)...if the nurses knew that they would not have to sacrifice 40 minutes of their shift simply to get and fill an order?? (time spent looking for forms and filing in a non-existent system where fax and phone numbers are lost in piles of stuff)..........the care would inrease because every nurse wants to to the best they can...but if faced between a med pass on a cart through 'cards' of meds.....for 20 or more patients........the immediate goal of med pass for all may surpass the 40 minutes lost searching for forms and numbers for the one!!!!!

I actually felt like a little girl "playing nurse" today....like the idealized slow, fun, caring profession from days of old. I have never felt like a child working in a hospital...(although the techincal, scientific stuff is great adult joy)...........I really got to get down to the basics at this SNF...see where I could easily and cheaply improve the system (of all paper)........and improve the whole facility to where their ratings could increase by at least 2-3 CMS stars by next year.

So, end of story...I may always PRN at a SNF...no matter how critical my caregiving may be in the hospital setting.........just because it is a pleasant break from the high stress life or death NOW reality of the hospital setting...have realized that SNF is a nurturing, loving environment......this one just needs alot of help....Just thought all of you would like to hear my final answer to my original question.......

Thank you all so much for replying! You were part of what helped me continue through this orientation week...and part of what makes me want to continue on with SNF work!!!!!!!!!!!!! YAY!!!! Now, I hope I haven't offended anyone here, cause all I found today was nice stuff!!!!!!!

allnurses Guide · Apr 2, 2011

Hi Nightengale! Thanks for updating! I wasn't sure if you had planned to stay at this place or not, but I can say that there is nothing more satisfying than having the ability and the cooperation of a willing staff to improve the lives of these people in my experience. So much of what we do by it's 24/7 nature gets tossed in the basket so to speak so we're at times denied seeing the tangible results of our efforts. It sounds like you've got a great opportunity if you do stay, and if you don't you will at least realize that there are LTCs with support staff who are not snarly and belligerent (a frequent complaint), so it will keep you hopeful should you decide to take another run at it later on. Best wishes to you! :) :up:

gentlegiver, ASN, LPN, RN · Apr 2, 2011

In so many LTC/SNF, the LPN's are considered "warm bodies" not taken as having any good ideas. What we need is someone who management will actually take seriously. As an LPN, I have restructured the filing system, updated paperwork to include information that is useful, organized the Med- Room. What it got me was more work, leaving me no time to continue "fixing" problems. Suggestion I made were sidelined, at a few places I was told I was not allowed to organize because someone else did it years ago and thier all used to it. But, I keep plugging along, I make what changes I can. I am glad you chose to stay with that company, the patients need you as much as the staff does.