Can anyone help me understand patient ratios?

sapphire18 · Jun 17, 2012

I am so sorry that your job is so stressful- I don't know how anyone handles ratios like that. I'm glad that the regional DON saw that you were doing the right thing and not the one to restrain the patient. Since you did NOT restrain the patient, you have no reason to worry about your license- it sounds like the CNA should be in trouble though. I don't really have anything helpful to add as I have never worked in LTC, but I just want to offer my support and wish you luck in finding another job, and that in the meantime your job is a little better for you. :hug:

Esme12, ASN, BSN, RN · Jun 17, 2012

Your State. The government.....Health and Human Services. The Joint Commission. The Department of Health in your state. The Center for Medicare and Medicaid Services. HOW they decide it...is beyond me.

State Long-Term Care: Recent Developments and Policy Directions

State-Initiated Nursing Home Nurse Staffing Ratios: Annotated Review of the Literature

Medicare.gov - Nursing Home Compare - Nursing Home Important Information

SB972 - Outlines minimum staffing requirements for skilled nursing facilities

http://www.theconsumervoice.org/sites/default/files/advocate/action-center/Harrington-state-staffing-table-2010.pdf

Nursing homes that receive federal funds must comply with federal legislation that calls for a high quality of care. Though all states must comply, at a minimum, with the federal regulations, some states have adopted tougher laws.

To participate in the Medicare and Medicaid programs, nursing homes must comply with the federal requirements for long term care facilities. Federal Regulations and Nursing Homes

Under the regulations, the nursing home must:

Have sufficient nursing staff. (42 CFR 483.30)
Conduct initially a comprehensive and accurate assessment of each resident's functional capacity. (42 CFR 483.20)
Develop a comprehensive care plan for each resident. (42 CFR 483.20)
Prevent the deterioration of a resident's ability to bathe, dress, groom, transfer and ambulate, toilet, eat, and to communicate. (42 CFR 483.25)
Provide, if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene. (42 CFR 483.25)
Ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. (42 CFR 483.25)
Ensure that residents do not develop pressure sores and, if a resident has pressure sores, provide the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. (42 CFR 483.25)
Provide appropriate treatment and services to incontinent residents to restore as much normal bladder functioning as possible. (42 CFR 483.25)
Ensure that the resident receives adequate supervision and assistive devices to prevent accidents. (42 CFR 483.25)
Maintain acceptable parameters of nutritional status. (42 CFR 483.25)
Provide each resident with sufficient fluid intake to maintain proper hydration and health. (42 CFR 483.25)
Ensure that residents are free of any significant medication errors. (42 CFR 483.25)
Promote each resident's quality of life. (42 CFR 483.15)
Maintain dignity and respect of each resident. (42 CFR 483.15)
Ensure that the resident has the right to choose activities, schedules, and health care. (42 CFR 483.40)
Provide pharmaceutical services to meet the needs of each resident. (42 CFR 483.60)
Be administered in a manner that enables it [the nursing home] to use its resources effectively and efficiently. (42 CFR 483.75)
Maintain accurate, complete, and easily accessible clinical records on each resident . (42 CFR 483.75)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107c07.pdf

Catzilla · Jun 18, 2012

The vagueness of this:

"Have sufficient nursing staff. (42 CFR 483.30)"

Admin. can say staff is "sufficient", just "work faster, smarter".

That is, until something terrible happens as a result of under-staffing.

chuckster, ADN, BSN, RN, EMT-B · Jun 18, 2012

While this must be a tough situation for you as well as the others working in the institution, I suspect that the patient-nurse ratios (and work loads) you describe are within most state's regs. They would be in my home state of PA, which I think allows something like one RN for upwards of 100 patients in LTC in the evenings.

Sorry to suggest this but your best bet may be to find a postion elsewhere.

Maremma · Jun 18, 2012

Indeed yes I have am back to work and the aid that I asked to watch the patient was ultimately found to be the one guilty of tying her fast to her chair and is terminated.

Yes I understand that patient ratios for LTC are what they are and although it can get busy and problems do come up when I work down a strictly long term care hall I can still manage it.

I am strongly questioning the sanity of using the same ratio though down my permanent hall. These people are NOT all long term care. The brunt of them are "rehab" patients coming straight out the hospitals. Many are not "just rehab" people from surgeries or car accidents ect. They are sending me unstable psych patients, or dementia patients that ALSO have broken bones PICC's nephrostomy tubes,peritoneal drains catheters, IV's, wound vacs, G--tubes etc. These people require FAR more care than a "long term resident" or a "normal" rehab patient that ONLY has the "car accident" or "physical limitations" that require rehab.

Imagine having MULTIPLE behavioral patients pulling out their PICC lines or IV's or yanking on their G-tubes, trying to stack furniture against their door to keep you out, beating the crap out of you because they are hallucinating that something is attacking them etc. Try bladder scanning and cathing a patient that was heavily drugged in the hospital then they cut them off from all those drugs and send them your way just in time for the crap to be wearing off and the poor guy has 1000 cc of urine stuck in his bladder! At the same time keep the patient in the next bed calm as they go off the deep end because their room mate is trying to strangle the nurse and they themselves are suffering a panic disorder along with their other physical issue that brought them there. yeah daily ordeals like this in the hall I work in right now. It never fails either, the domino effect happens every time one psych patient goes downhill, the rest follow.

Indeed it is in my best interest to look for work elsewhere and I am trying but I still don't have my first full year experience yet and so it is making if rougher to get hired anywhere else yet. Still even if I do find another job that still leaves the problem for these poor patients and the next nurse that is put down there permanently. God help them. On my days off the nurse's that have to work my hall dread it and go home crying. One outright quit. Another went to overnights to avoid having to work the 3-11 down this hall. I am hoping that there is a lower ratio for nurse AND aid to patient ratio for "rehab" patients that the facility just isn't recognizing down that hall yet. Particularly PSYCH/rehab patients. it wouldn't be the first thing they did not recognize until an outside source told them they can't be doing something they are doing.

wendowen · Jun 18, 2012

First I want to say .. I am sorry, I have worked SNF rehab and understand the messy side of it, I have also worked hospital recently and understand that it is not the hospital that kicks people out, it is the goverment regulations that people only have so many DRGS days for their dignosis, if they use up all there hospital days then bye bye its off to snf to recouperate... yes people are sicker today then they were 40 years ago, becuase of the advancements in health care.. nursing homes are turning to rehab to make a dollar becuase that is where the money is.. dementia pts dont pay for the light bill.. if you have to work snf rehab work nights if you can until you can find a better job.. I used to be an LPN worked snf and hated it, went back and got my RN worked hospital and am now doing hospice.. there are always better jobs out there.. keep your head up.. and apply apply apply... the right job will to you... hang in there..

Esme12, ASN, BSN, RN · Jun 18, 2012

Indeed it is in my best interest to look for work elsewhere and I am trying but I still don't have my first full year experience yet and so it is making if rougher to get hired anywhere else yet. Still even if I do find another job that still leaves the problem for these poor patients and the next nurse that is put down there permanently. God help them. On my days off the nurse's that have to work my hall dread it and go home crying. One outright quit. Another went to overnights to avoid having to work the 3-11 down this hall. I am hoping that there is a lower ratio for nurse AND aid to patient ratio for "rehab" patients that the facility just isn't recognizing down that hall yet. Particularly PSYCH/rehab patients. it wouldn't be the first thing they did not recognize until an outside source told them they can't be doing something they are doing.

The regulations for behavioral restraint are on set of rules and a completely different set of regulations for restraint due to medical device restraint.

Staffing? Unfortunately to some degree is highly variable...but there are different regulations for a LTC patient and a Rehab patient AND there is a difference in reimbursement from the government for this level of care....look for another position but you can always report them. Call the ombudsman of you state. Use the "report" tags on the CMS/Joint Commission site. Call the board of health with an anonymous complaint.

I wish you the best...:hug:

Maremma · Jun 18, 2012

Ahhh okay so maybe I can also begin to understand some of the other "crazy" stuff that I keep see happening when patients come in from the hospitals. More than once these people have been "chemically restrained" at the hospital. Heavy medications were being administered that kept them "knocked out" so to speak due to their behaviors while there. This is perfectly legal, accepted practice and routine correct?

Once they leave there though and come to us they are just cut off cold turkey.They are simply "swapped" to the regs of a LTC facility which required we do NOT chemically restrain unless ABSOLUTELY necessary and ONLY after all other methods have failed. (Usually meaning someone has to get hurt before they will even consider small doses of any medication to calm them)

So not only are these people completely off their normal regular meds that their personal Dr worked years to stabilize them on. (This has happened over and over and over when they land in the hospital) They are then heavily sedated with other heavier drugs to control the behaviors they then display at the hospital,due to being stripped of the meds they had been on for years before hand. Frequently these people also the come to me with horrible pressure ulcers some requiring wound vacs that were acquired while in the hospital. It doesn't take a rocket scientist to figure out that these people were so heavily medicated they couldn't move at all to have developed such terrible ulcers. (and that they most likely were not turned and repositioned often enough)Once the drugs wear off these people are ALL OVER the place, VERY capable of far more than repositioning themselves is putting it nicely. Can anyone explain the rationale to why we do this with psych patients rather than keep administering the meds they were on before they landed in the hospital? I am beyond dumbfounded every time I see this in their charts.

Then when it is time to leave the hospital we STILL do not put them back on their regular routine meds and cut them off cold turkey from the heavier things they were taking in the hospital and have to not only have the patient displaying all the S/S of their original mental health disorder we now have them in withdrawal to boot. My head spins at the seeming lunacy of this practice. WHY do we do that? How in the world do we justify this?

Is this how ALL hospitals and nursing homes do things? It amazes me that there are not all kinds of law suites against the hospital and us from than families of these patients. More than once I have heard from the patients family that their loved one was stable and "doing well" with their psychiatric disorder and then everything went downhill at the hospital. The families are not stupid, they know full well the hospital took their loved one off the meds they were on. They also met brick walls when begging the hospital to give them their meds they were receiving at home. O course they only ever get the nurse who can do nothing but explain that the Dr has to order the meds we cannot just give patients meds at family request. So then they are holding out hope that "as soon as" they get out of there and to our facility their loved one is going to get "put back on track". Alas no so luck here either! Then I have very angry family members to try to deal with too. I just can't get it. "if it ain't broke don't fix it" seems like a real good idea when a psch patient comes along that also has an acute physical problem.

ncat · Jun 18, 2012

any facility u work in should watch out for satff and pt populations. u may have to find another job in another faclility to save your own sanity and skills. we all develop a short way of doing things, but sometimes with that scenarion-how can u do this safely. also-i am sure other faclitities in your area have heard about this facility as word travels fast in the medical world. u can always change jobs citing there is a professional dis-agreement on philosophy of care. remember-u must watch out for your performance and gaurd your lisc.-keep your own mal-practice insurance and practice safe.

BearishBob · Jun 18, 2012

Can you go back to school and get your RN? You would have more options as an RN. Like quitting the job you have now.

The only state that has state mandated nurse to patient ratios is California. However, its not all sunshine and roses there. The hospitals have just fired all the ancillary staff to make up for it.

Maremma · Jun 18, 2012

Well isn't that so nice of California health care facilities! Well I suppose they are going to learn their lessons the hard way too. They have eliminated all the LPN's at the hospitals around here. It is really sad all the way around. The patients are receiving far less care now and many more serious errors are happening to them because of this decision.

The facility I am working at has some real long term nurse's. They tell me "how it used to be back in the day". They said quite shortly after the hospitals did what they did we began receiving more and more patients in worse and worse condition coming directly from them. Including these deep to the bone infected pressure ulcers that require wound vac and IV antibiotics. They said when the LPN's were still in staff with the RN's they NEVER received patients from there in such horrible conditions.

RN's can only do so many jobs at once too. it is so sad that the greed of these places is creating such horrible outcomes for all concerned.

The original plan was to get my LPN while I worked as a CNA then work as an LPN while I continued on in school to get an RN. I have health issues though that I will need to be able to get back under control before I even dare to try juggling it all again.Going from early morning til late night seven days a week for a year and half straight did a number on me that I still have not fully recovered from. Of course the paying for it also plays a huge factor in going back too. I would love to keep continuing my education, the heart is willing, the body and finances not so much.