California patient Ratio

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I posted this thread at the other forum but not many people responded. I have questions about Cailfornia's patient's ratio law on the telemetry-med surg unit. Hopefully somebody will answer me. I just transferred from stepdown unit to tele med surg. I have 5 patients on my own, covering 3 LVN patients and 1 or 2 primary care patients, Team nursing is NOT implemented in my new unit and the LVN did absolutely NOTHING for my own 5 patients, but if something happened to those 3 LVN patients, I have to call the MD for them, if there is an admission, I need to get a report for them. Also I need to carry their orders and check their orders for them. I don't mind giving their IV med. I feel so overwhelmed and frustrated at work. In my opinion, it seems out of the ratio. What do you guys think about it? And what can I do about it aside from complaining to my manager? He (my manager) claims he cannot change anything, I can't quit right now because I have a year contract (3 months). I will be out but in the meantime, I want to make sure I am working in a safe place. Can anybody tell me which hospitals in the LA area strictly enforce the ratio law and not burn the nurses out every shift?

The regulations state, "The licensed nurse-to-patient ratio in a telemetry unit shall be 1:5 or fewer at all times."

If you are responsible for a patient shared with an LVN you have more than five. That is NOT legal.

Your posts proves you know your hospital is flaunting the law.

Also, Section 70217 of Title 22 states, "The hospital shall implement a patient classification system as defined in Section 70053.2 above for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse."

and

"Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system".

This would mean adding an LVN to assist in order to provide safe care.

When the DHS came up with the ratios they based them on the skill mix in place in 2002. For telemetry units that was 17% LVN. Even the DHS knows the safe minimum ratio is 1:4. That is why in 2008 the minimum ratio for telemetry will be four or fewer patients assigned each nurse.

http://www.dhs.ca.gov/lnc/pubnotice/NTPR/R-37-01_Regulation_Text.pdf

http://www.dhs.ca.gov/lnc/NTP/default.htm

I went to these website links and found nothing r/t LVN assignmnets. There was in the FAQ section of one a Q/A Heading regarding same, but the actual Q/A seems to have been removed.

It is a very confusing business as the hospital I am at uses an RN-LVN team to cover up to 9 mixed surgical acute patients. The administration is hoping to have the RNs share the paperwork load with the LVNs as well as the direct patient care. They stress that the LVNs are trained in assessments, care planning, etc.

It seems some of the long-time LVNs have no interest in adding paperwork to their burden. Some of the new LVNs have a different outlook and want the added responsibility. I do think that LVNs could be assessing POD #2 or #3 and beyond, provided the patient is recovering as expected, and no change of condition has been noted.

The problem seems to be in the way pts are assigned. If the patients are assigned to an RN-LVN team, isn't the RN always responsible for delegating and follow-up? If, as in rural hospitals, the LVNs receive a patient assignment with an RN to cover a scattered IV ABX, who is overseeing the LVN?

It still seems very interpretation and pint of view driven.

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I cannot interpret this to mean anything other than that each patient must be assigned a registered nurse.

TITLE 22.70215. "Planning and Implementing Patient Care

(a) A registered nurse shall directly provide:

(1) Ongoing patient assessments as defined in the Business and Professions Code, Section 2725(d). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area.

(2) The planning, supervision, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation.

(3) The assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. Any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient.

(b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission.

© The nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient.

(d) Information related to the patient's initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient's medical record."

Using this link:

http://ccr.oal.ca.gov/linkedslice/default.asp?SP=CCR-1000&Action=HOME

Click Title 22

Then Licensing and certification of health facilities

Then Acute Care Hospitals

Then Basic services

Then Nursing care services section 70215

-------------------------------------------

The practice of vocational nursing within the meaning of this

chapter is the performance of services requiring those technical,

manual skills acquired by means of a course in an accredited school

of vocational nursing, or its equivalent, practiced under the

direction of a licensed physician, or registered professional nurse,

as defined in Section 2725 of the Business and Professions Code.

http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=02001-03000&file=2859-2873.6

The LVN in California may not practice independently. In acute care the RN providing clinical supervision must be present and available. If you have a full assignment you are not available. You are not available when you go to lunch.

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In the unit I work at (Med-Surg...mostly post op patients or awaiting for surgery) we sometimes do team nursing. If I have 10 patients, I will have an LVN and CNA working with me...The LVN will do all the PO meds and treatments (dressing change, F/C insertion, G-tube....) then the CNA will do all personal hygienes, vital signs, I/O's....I do all the assesments, IVP, IVPB, blood transfusion and calling Docs for critical labs and any changes in our patients status and clarifying and implementation of orders....Now, we also do TPC (total patient care), in this case we are only assigned 5 patients with a CNA no LVN...

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I think team nursing is a very hard thing to do. 5 patients with CNA OR 1 TO 2 Total patient care is great. I worked in a unit where is only 3 reqular staff RNs every night, the rest is registery LVNs. I worked with several LVNs,they totally depends on me and the CNAs. Charted all the assessments to all WNL even the pt was all extremeities flaccid, pupil dilated, BKA on left, stage 3 decubitus on the sacrum. I went to the nursing office to file compliant to the LVNs then DNR for while then come back to work again after 2 months. I 'm sick of these games. Recently the hospital has MOCK JACHO, all the sudden follow all ratios rules. If they know it is legal then why need to change!!!!!!!!!

Guilty???

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You sound like a thorough nurse. Please do not blame LVNs only for doing poor assessments. I have worked with RNs who chart assessments on the wrong patient chart (and never notice), and who also chart WNL when they are obviously not. I won't go into the RNs who thought D5W and D5NS were the same thing, that a UA specimen could be taken from a long hanging foley bag, or that Lovenox could be given in the arm. One of our instructors used to chuckle that WNL meant We Never Looked.

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If this is true, then what do you interpret as the team nursing "legal scenario"? If an RN and LVN team have 9 patients in Surgical Acute, is the hospital out of compliance? Or is it allowable because of the term licensed (and subsequent definition that includes LVNs) in the original draft of the law regarding patient ratios in CA?

(In regards to spacenurse post #14)

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In the unit I work at (Med-Surg...mostly post op patients or awaiting for surgery) we sometimes do team nursing. If I have 10 patients, I will have an LVN and CNA working with me...The LVN will do all the PO meds and treatments (dressing change, F/C insertion, G-tube....) then the CNA will do all personal hygienes, vital signs, I/O's....I do all the assesments, IVP, IVPB, blood transfusion and calling Docs for critical labs and any changes in our patients status and clarifying and implementation of orders....Now, we also do TPC (total patient care), in this case we are only assigned 5 patients with a CNA no LVN...

I can see this working OK IF it is safe for the patients.

If you know the competence of the LVN and CNA you are working with and the acuity allows this.

Title 22 Section 70217 states in part, "The hospital shall implement a patient classification system for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, licensed psychiatric technicians, who shall be assigned to direct patient care."

Teams can work well. There can be big problems if you suddenly have to work with a registry LVN who is less experienced or not aware of how team nursing works on your unit.

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