Choose your words wisely....

[Jo Dirt]

It is believed the nursing home where I work will be likely facing a possible lawsuit over a patient who has had a lot of falls lately. She is in her 90's and is not able to ambulate, though she can stand for transfers. She will try to either get out of bed by herself or put herself to bed and end up in the floor. The POA (who is not a relative) has become increasingly frustrated over the facility "allowing" her to fall. I have actgually had to fill out two of the incident reports on her in the last few months. I really do not believe it was the facility's fault, there are simply not enough people to hover over her every minute. We have taken every precaution we can (bed and chair alarms, low mattress with cushioned pad next to the bed, frequent reminders not to attempt to get up without assistance) but in spite of it she still has been falling. And it's nothing personal against this patient but she is as big as a cow and very clumsy.

Anyway, the most recent incident involved a minor bump to the head which resulted in a small inter (or intra) cranial bleed. She actually seems more alert and with it than she was before. We had a meeting about it. Apparently the nurse who called to report this to the POA said "the CNA dropped her." This was not what happened, but the administrator said when you have people looking to zero in on a lawsuit every word you say can and will be used against you. He went on to mention that another nurse in another report told her the reason the patient fell because we were "short" and since the patient wasn't put to bed when she was used to going she tried to put herself to bed.

Well, he didn't mention any names but this was me. I don't specifically remember telling the POA we were "short" but apparently I gave her the impression we were short staffed. The administrator said NEVER tell anyone you are short staffed, which we were not. I just wonder if this is going to come back to haunt me. I do not think this patient has suffered irreversible damage for this, but knowing how sue happy people are it just kind of eats at me.

BTW, it was the truth when I told the POA there was a call in which left us with not as much help as we usually had.

[Xbox Live Addict]

Also not to be judgmental but short staffing is always the NH's fault. Even if there is a call in the staffing coordinator should have multiple contingency plans and plans for if the contingency plans fall through. Of course I am speaking as a Staffing Coordinator. While nurses can be hard to get sometimes, there are always large amounts of CNAs and HHAs willing to be on PRN pools for the occasional shift here and there.

The one distinct thing I remember from my previous nursing homes is that when people called in there was 'minimal' effort to replace them and that's being generous. Many places I see consistently have holes in their schedules and barely have a PRN pool. There is never a real excuse to be short staffed unless the NH happens to be in a very small area with a small population. Even if they have to cut deals with agencies...

I agree with you that a NH should never be short-staffed. I also have seen at best half-hearted efforts at a PRN pool in LTC. Unfortunately, I know the nature of the beast... and that nurses and aides are too often blamed for the fundamental flaws in the NH system, fairly or no.

Here where I live, it is easy to play fast and loose with the state's mandated staffing ratios. The state mandates x number of residents per nursing staff. However, nursing staff includes both licensed (RN, LPN) and UAP (CNA, CMA) personnel... and administrative staff such as the DON, ADON, MDS coordinator, staffing coordinator, restorative CNAs, and even the person in charge of central supply, who is usually a CMA or CNA. So, if you have a 7:1 ratio on day shift, in a 90-resident facility. That means at least 13 staff members have to be present to be in compliance. Let's see, the typical NH in my area has:

1 DON

1 ADON

1 MDS nurse

1 staffing coordinator (LPN or CMA)

1 central supply CMA

1 restorative aide (sometimes 2)

2 charge nurses

2 CMAs

8 CNAs... on a good day (2 per hall)

18 total staff, which the State of Oklahoma says should be able to handle 126 residents. So five staff members can call off and the facility is still "legal." While most nursing homes do at least try to keep 1 CNA to a hall, that's still minimal care, with all the dressing, feeding, toileting and bathing that has to be done, forget about doing it the way it is SUPPOSED to be done. 1 CNA per hall to do all that. And the nurses at the top are mixed in how they will assist. Some caring DONs or ADONs will roll their sleeves up and do whatever's needed. Most of them prefer med pass, but a few are nurse enough to do the grunt work of ADLs. On the other hand, there are plenty of these administrative types who have told me "you'll have to fix it the best you can" while they head back to their nice quiet office. CNA call-ins are frequent. Some of them have family problems that won't leave them alone at work. A minority of them are just lacking any motivation. Most of them are busting their butts trying to take care of these people while being dumped on, and leaving when they absolutely cannot take another day of it!

It's even dicier on 3-11 and 11-7. The staffing ration on 3-11 is 1:11, and on 11-7 it's about 1:18. So that means a charge nurse to run three aides and a CMA. And when you complain, you're told "we can't get any more staff, you'll have to buckle down and get to work."

Weekends, likewise. Would someone explain to me why a NH - a 24-hr-a-day, 365 day a year operation, continues to do weekend staffing the way that customer-based businesses do, with minimal staff on weekends? A customer based-business lightens its weekend staff because of decreased demand for their services/goods. But a chronically ill NH resident is just as sick Sunday as they are Wednesday, and emergencies don't take weekends off either. So why are they running with bare-bones staffing and no administrative staff around (with the charge nurses doing the admin's duties) on weekends?!

[Xbox Live Addict]

Only asking because when I was in the Medicaid/Medicare nursing homes, I don't really have memories of excess falls. Maybe one or 2 people but we always had them covered and knew their routines...

Hmm maybe private pay has spoiled me.

It gets to be a problem the more of them there are. If you've got multiple patients that are serious fall risks, especially ambulatory residents prone to elopement, that makes it tought to ensure great safety.

Thanks to SNF, the acuity of NH residents is skyrocketing. Many patients in for NH care not so long ago. would have been in the hospital to receive that same care.

[BinkieRN, BSN, RN]

I wasn't the nurse who said the patient was dropped, but I was the one who said we were working without as many aides. In the nursing home's defense, they actually staff more than state regulations require. Just happens that call-ins always leave you in a bind.

I got that. It was the CNA who said the patient was dropped. You said you were working short or something to that effect, had a call-in whatever.

Don't defend the nursing home, they'll gladly hang you out to dry when it comes to a lawsuit. Best of luck.

[Atheos]

I agree with you that a NH should never be short-staffed. I also have seen at best half-hearted efforts at a PRN pool in LTC. Unfortunately, I know the nature of the beast... and that nurses and aides are too often blamed for the fundamental flaws in the NH system, fairly or no.

Here where I live, it is easy to play fast and loose with the state's mandated staffing ratios. The state mandates x number of residents per nursing staff. However, nursing staff includes both licensed (RN, LPN) and UAP (CNA, CMA) personnel... and administrative staff such as the DON, ADON, MDS coordinator, staffing coordinator, restorative CNAs, and even the person in charge of central supply, who is usually a CMA or CNA. So, if you have a 7:1 ratio on day shift, in a 90-resident facility. That means at least 13 staff members have to be present to be in compliance. Let's see, the typical NH in my area has:

1 DON

1 ADON

1 MDS nurse

1 staffing coordinator (LPN or CMA)

1 central supply CMA

1 restorative aide (sometimes 2)

2 charge nurses

2 CMAs

8 CNAs... on a good day (2 per hall)

18 total staff, which the State of Oklahoma says should be able to handle 126 residents. So five staff members can call off and the facility is still "legal." While most nursing homes do at least try to keep 1 CNA to a hall, that's still minimal care, with all the dressing, feeding, toileting and bathing that has to be done, forget about doing it the way it is SUPPOSED to be done. 1 CNA per hall to do all that. And the nurses at the top are mixed in how they will assist. Some caring DONs or ADONs will roll their sleeves up and do whatever's needed. Most of them prefer med pass, but a few are nurse enough to do the grunt work of ADLs. On the other hand, there are plenty of these administrative types who have told me "you'll have to fix it the best you can" while they head back to their nice quiet office. CNA call-ins are frequent. Some of them have family problems that won't leave them alone at work. A minority of them are just lacking any motivation. Most of them are busting their butts trying to take care of these people while being dumped on, and leaving when they absolutely cannot take another day of it!

It's even dicier on 3-11 and 11-7. The staffing ration on 3-11 is 1:11, and on 11-7 it's about 1:18. So that means a charge nurse to run three aides and a CMA. And when you complain, you're told "we can't get any more staff, you'll have to buckle down and get to work."

Weekends, likewise. Would someone explain to me why a NH - a 24-hr-a-day, 365 day a year operation, continues to do weekend staffing the way that customer-based businesses do, with minimal staff on weekends? A customer based-business lightens its weekend staff because of decreased demand for their services/goods. But a chronically ill NH resident is just as sick Sunday as they are Wednesday, and emergencies don't take weekends off either. So why are they running with bare-bones staffing and no administrative staff around (with the charge nurses doing the admin's duties) on weekends?!

That's horrible. We only have 49 beds and always have 6. If we have 5 d/t a callout then we pull the restorative aide. Having 5 aides has only happened twice. We consider it unacceptable. Those 6 aides are on top of 2 Floor LPN, 2 Unit Managers(1 LPN and 1 RN), 1 restorative aide, 1 central supply aide, 1 MDS nurse (lpn), 1 administrator coordinator (CNA, hich is me but is a wierd staffing/administrative supervisor position) and the DON (RN).

On evenings we only lose the admin people but gain a RN supervisors and on nights we have 2 LPNS and 4 aides. Anything less would be ludicrous.

One day nursing homes will realize that better staffing = better service = a waiting list of private pay people waiting to fill your beds. I never understood the minimal staffing idea. A better facility can eventually weed out medicaid which results in more money AND less state.

The number of medicaid.medicare people we turn away is ridiculous. One family actually screamed at us and said it wasn't fair to only take care of rich people. What's funny is we only have like 2 'rich' people. Most of our patients were career military (not all officers) and made good choices with their money.

One day someone will get it I am sure...

[HM2VikingRN, RN]

Its one of the reasons that I won't work LTC. I can't in good conscience provide care to patients in an unsafe environment....

[VICEDRN, BSN, RN]

For whatever its worth, I used to be a paralegal and I can tell you that the best way to avoid a lawsuit is to be honest with people and apologize. This way, they feel they can work with you.

Otherwise, suspicion starts to grow which leads to resentment and beliefs that malicious behavior are at the root of lies. Lawsuits bloom in this environment.

Go ahead, be honest is my opinion. Spin it the best way you can but don't cover up the truth.

[NursKris82]

I work in LTC and we have several people in our building who have frequent falls. We put alarms of them and keep and eye on them, but we cannot restrain them. They have the right to fall. The most important thing here re. a lawsuit is to document, document, document. Document that the alarms were in place and when you catch her tyring to transfer herself and assist her. As far as the statements made, they are right! You never want to admit responsibility, especially with a resident that has a history of falls. You cannot be with that resident at all times, they knew that when they were admitted to the facility. So, she fell because someone couldn't put her right to bed, that could have happened due to short staffing or for any numbers of reasons on a diiferent day. The facility has to do everything within it's ability to prevent falls (alarms and so on) without overstepping the resident's rights (to be free from restraint and maybe fall). The reason the facility says that we aren't short staffed is most times, they are not, according to the riduculous state ratios. Which goes by the number of patients and counts all nursing faculty together for a total number, including managers and everything. Rapport is key to avoiding a lawsuit and if they were sued your statement will likely be brought up against the facility. The most important thing to stress is that this resident has rights, just like sick, mentally ill people have the right not to be drugged to make their life better, this resident has the right not to be restrained to make hers better. A good manager needs to sit down with this POA and explain residents rights to her, period.

[pagandeva2000, LPN]

Just a question...

I work at a private pay facility (which might be why I am under the impression that I am). When we have patients that fall constantly despite all the normal interventions it is normal to have a HHA specifically for them. Is this not the policy everywhere. Profits notwithstanding, isn't this a reasonable intervention. Shouldn't nursing homes be responsible for this?

Now I do understand that nursing homes are businesses and that businesses are about making money but isn't a nursing home responsible for maintaining adequate staffing and taking ALL reasonable steps to ensure the safety of it's residents?

Of course the OP doesn't say how the resident is falling but surely something can be done to address it. Technically if a nursing home is working short, they are at fault. We do have falls as well but we do everything possible from floor level beds to recliners to an extra aide. Maybe being in a private pay environment has spoiled me. Is my thinking unreasonable???

Now, I have seen this done once or twice at one of the nursing homes I worked at as an aide, but it didn't last long. So, yes, StanleyRNtoB...such situations have existed on my side of the planet.

[Vito Andolini]

It is believed the nursing home where I work will be likely facing a possible lawsuit over a patient who has had a lot of falls lately. She is in her 90's and is not able to ambulate, though she can stand for transfers. She will try to either get out of bed by herself or put herself to bed and end up in the floor. The POA (who is not a relative) has become increasingly frustrated over the facility "allowing" her to fall. I have actgually had to fill out two of the incident reports on her in the last few months. I really do not believe it was the facility's fault, there are simply not enough people to hover over her every minute. We have taken every precaution we can (bed and chair alarms, low mattress with cushioned pad next to the bed, frequent reminders not to attempt to get up without assistance) but in spite of it she still has been falling. And it's nothing personal against this patient but she is as big as a cow and very clumsy.

Anyway, the most recent incident involved a minor bump to the head which resulted in a small inter (or intra) cranial bleed. She actually seems more alert and with it than she was before. We had a meeting about it. Apparently the nurse who called to report this to the POA said "the CNA dropped her." This was not what happened, but the administrator said when you have people looking to zero in on a lawsuit every word you say can and will be used against you. He went on to mention that another nurse in another report told her the reason the patient fell because we were "short" and since the patient wasn't put to bed when she was used to going she tried to put herself to bed.

Well, he didn't mention any names but this was me. I don't specifically remember telling the POA we were "short" but apparently I gave her the impression we were short staffed. The administrator said NEVER tell anyone you are short staffed, which we were not. I just wonder if this is going to come back to haunt me. I do not think this patient has suffered irreversible damage for this, but knowing how sue happy people are it just kind of eats at me.

BTW, it was the truth when I told the POA there was a call in which left us with not as much help as we usually had.

Doesn't sound good, sorry.

I think the truth is that any facility is short-staffed whenever it has fewer people than are needed to "hover" adequately, including your facility. Today, that's just about everywhere - everywhere that nurses and aides are expected to be like non-stop, non-thinking automatons, with the assembly line speeded up faster and faster and faster.

[FranEMTnurse, CNA, LPN, EMT-I]

When I was a nursing student, I did two clinical rotations in a county run nursing home. One day that was especially busy, I asked a staff member that if they get overwhelmed with too many residents to care for what happens. The individual told me that the residents who aren't able to get out of bed are left for last, and if the staff doesn't have time to care for her/him, then the resident was left in bed. I assumed the bedridden resident would be cared for during the second shift, and day shift personell would let the second shift personell know that resident didn't have care yet due to understaffing and overworked personell. At least I hope so.:stone

[ktwlpn, LPN]

I work in a 220 bed non-profit county run LTC -very few private pay residents. We implement strict 1 to 1 for residents like this. It makes more sense then allowing a resident to fall 27 times in a month (the family were NOT pleased-the DOH even less so. Most of the incidents happened because the fellow was left in the dining room alone after dinner-night after night after night.Or he had climbed out of bed and fallen in the doorway of the room-and then was put back to bed and left to climb out and stagger to the doorway TO FALL AGAIN. HELLO-leave hime up with a drink and a snack for a while....BUT-people have to understand that falls will happen and we can;t tie these people down...not with duct tape,velcro or bed sheets...darnit

[Jo Dirt]

I got that. It was the CNA who said the patient was dropped. You said you were working short or something to that effect, had a call-in whatever.

Don't defend the nursing home, they'll gladly hang you out to dry when it comes to a lawsuit. Best of luck.

Well, actually, the nurse who called the POA to report the incident is the one who said she was dropped.

But that is neither here nor there at this point.

I have no doub they would try to throw us under the bus when push comes to shove, but I don't really think I said anything wrong.