Dirty little secrets to managing LTC

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Specializes in Med-Surg, Home Health, LTC.

I am mostly acute care experienced but working through agency and there are a lot of LTC shifts coming my way.

I have worked at facilities that staff from 15:1 to 40:1.

This weekend I worked at a 40:1.

First time at this facility.

Unbelievable. There is no way a nurse can safely and legally give all meds to all patients!!

I had to ask for help and had another nurse take part of my team.

The oncoming (staff) nurse gave me one of her tips.

She signs the narc sheets at beginning of shift! All of them!

Signs she took out the medication, the time, the remaining number!

Unbelievable.

In California and maybe elsewhere facilities are getting tighter and increasing number of patients

on each team. So in my mind, I now understand , there are many nurses that need a job so badly they

are willing- and DO- things like above. Just to cope. Just to manage. Because we all need to work.

(Well almost all of us here)

So illegal practice and compromising patient safety are probably more common than is ever spoken.

Hence I call it the dirty little secrets of LTC nursing.

How many of you do the above? Or skip routine meds like vitamins or minerals and just sign the mar?

Chart something you did not do? What are all the dirty little secrets kept by LTC nurses?

Is this the way of the world now? Why aren't nurses coming together and demanding legislature to change

these unsafe ratios? Because until we do it will never get better and will only, as it is now, become much worse.

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I've asked similar questions relating to, "Why we don't all come together and demand change". Heck, "Registered nurses (RNs) constitute the largest healthcare occupation, with 2.6 million jobs". http://www.bls.gov/oco/ocos083.htm.

I write letters, talk to people and try to explore ideas to make systems better. Let's hope others follow suit.

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just a question about the nurse that presigns the narc sheet...what if she signs out a med, and the pt dies before it's due....?

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just a question about the nurse that presigns the narc sheet...what if she signs out a med, and the pt dies before it's due....?

Well, I don't know what "she" would do, but I can tell you what "the nurse" might do.

It's not that big a deal. By that I mean it is easy to fix. If you signed it out and the patient dies, you just go back during count, cross it out and correct the count on the side. I regularly see nurses sign out a med, get distracted and not give it, give a med and forget to sign, pre-sign, sign at end of shift during count... when you (or someone else) realizes the mistake you just pop it out and dump it into the sharps. I am willing to bet there are nurses that dump it into their pocket instead. (i personaly don't pre-sign. i make a real effort to do it by the book because in my experience i make fewer errors that way and i don't have to do a "pre-count at the end of my shift because i know the count is correct)

There are MAR signing errors on any station/shift/nurse. I have never seen anyone NOT make mistakes including myself (that is one reason for going to electronicaly dispensed meds) and the people in the real world are aware of that including the state. That is why the state doesn't look at every MAR for every error. They find a couple, take note and move on. (unless they are investigating and need to find proof of poor work..) I am in no way defending any of the things I listed... Just some real world things I have observed. It will be nice when LTC/SNFs go to electronicly dispensed meds and computer charting like the hospitals. I know some in california have.

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I have regularly passed a massive amount of meds on a unit of 44. Without errors and on time. Yes, it takes practice, and yes, I do it BETTER by not taking shortcuts.

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Specializes in Gerontology, Med surg, Home Health.

If you get into a rhythm, it is possible to safely and correctly medicate 40 residents with ALL their medications.

Things won't change unless the residents and their families demand it. Nurses can 'demand' all they want. There is always someone willing to do the job. And you don't need 1 nurse for 15 residents on a long term care floor...you just don't.

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I have regularly passed a massive amount of meds on a unit of 44. Without errors and on time. Yes, it takes practice, and yes, I do it BETTER by not taking shortcuts.

Please know I don't mean to call you out on this but if I recall correctly this was on third shift, correct? Were you giving a lot of meds to these people or just things like prilosec or synthroid? Didn't you end up having to change the times on some of the meds to get them done?

Thank goodness I only float to the LTC floor a few times a year. I have a 15:1 ratio on my subacute floor. When I go to the LTC floor and have the 9 am med pass for thirty patients I am in an impossible situation.

If it was mostly just pills, maybe...MAYBE once I learned the med pass really well (ie...memorized it) I could get it done within three hours. But with the TONS of lidoderm patches (love getting to everyone's lower back after they're already dressed and in their chair), inhalers, nose drops, ear drops, eye drops and number of people who get a potion or nostrum to every orifice and part of their body it ends up taking forever. For the 9 am med pass my window is from 8 am to 10 am per the rules for one hour before and one hour after. I try to start by 7:30 latest (have to beat the trays with fingersticks and insulins) and I am passing those meds until noon, at which time I get accuchecks and insulins again and roll right into the afternoon meds without a pause. If I'm lucky I finish the meds by 2:30pm, leaving half an hour for treatments, charting, etc. This is with most patients on weekly BPs and not daily, only a couple PEG tubes and not too many that require crushing and cajoling to take their meds.

It gets really bad because people have QIDs that are supposed to be given at 9am and 1pm and here I am giving them their 9am at 11:30...am I supposed to give them another dose of hydralazine or whativer only an hour and a half later?

LOTS of people who are out and about though, and trying to track them down can be time consuming. After breakfast not many are in their rooms.

The regular nurses on those floors take massive shortcuts. The first time I worked 11-7 on the LTC floor I was told by several nurses that if I didn't prepour the meds I'd never finish. I didn't prepour them and had to start at about 4am to get done 7am...and that's with 30 patients and maybe 6 or 7 get their daily pills at 6 because they are early risers the rest getting the usual 6 am meds and lots and lots of accuchecks.

Anyway, long winded way of saying I can't even fathom passing meds to 44 patients. I don't care what anyone says, that is just too many. 30 is too many, but that should be the absoloute maximum (and I think 20-25 would be more reasonable still.)

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One thing I hate is the huge number of Miralax, metamucil, beneprotein, 2 cal, benefiber and other such supplements/liquids we're giving out. People HATE them and I have to stand there and take forever to "encourage" them to take all these things.

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Specializes in LTC, Med-SURG,STICU.

I don't know about 40 residents, but I do regularly pass meds to 30 residents. I have found that if I delegate appropriately and nothing unusal happens I should be able to get the 0900 med pass done on time and properly. I usually have the CNAs get the vital signs and everyone knows to not bother me unless it is something that must be addressed imediately. They will leave a note taped to the nurses desk or to my cart (covered of course) for me to read as soon as my med pass is done. At times I have had a notebook that I kept on the cart so that the CNAs could leave me notes in that.

I will tell you this much I never skip meds to save time. The only time I hold a med is if after my assessment it is in my best nursing judgement to hold a med. Then I contact the doctor ASAP to inform him/her of my findings and to recieve orders on whether or not to give the med. I do not like it when nurses do not give meds as ordered and I will write them up if they do so.

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Specializes in LTC, Med-SURG,STICU.

NOTFLO why are you doing nose sprays, eye gtts, and patches on the 0900 med pass? Those are done on the 0600 med pass so that it is possible for the day shift nurse to complete the med pass close to the 3 hour time frame. I couldn't agree with you more on the supplements.

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Specializes in Professional Development Specialist.
NOTFLO why are you doing nose sprays, eye gtts, and patches on the 0900 med pass? Those are done on the 0600 med pass so that it is possible for the day shift nurse to complete the med pass close to the 3 hour time frame. I couldn't agree with you more on the supplements.

In my facility some nurses have been known to reschedule meds so that there are NO meds or treatments given on the NOC shift. There are some meds on the evening shift but lately even the bs readings that were done at 6am are now done at 7 and therefore my responsibility. I start at 6am doing dressing changes and skin treatments like mad so at 7am I can start my 8am med pass and finish by 10am. I don't pre-pour and I don't memorize. I can't imagine how you could, the meds on my pts change all the time. But I can tell others do memorize, because they are missing a massive amount of new orders each day until it is passed on in report to please start giving the med you've missed for 2-4 days. It's depressing.

ETA- I am sure some sign off on the supplements, etc. I noticed one day that the other nurse had no supplement on his cart all day like I generally do. I asked and he answered vaguely that few of his pts are on it. Now that I work that cart every day I know nearly everyone should have been getting it. :(

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Specializes in LTC.
One thing I hate is the huge number of Miralax, metamucil, beneprotein, 2 cal, benefiber and other such supplements/liquids we're giving out. People HATE them and I have to stand there and take forever to "encourage" them to take all these things.

I hate them too. I am not going to stand there and make them drink it. If they don't want it.. I dont make them drink it. I am moving on and not wasting precious time making them drink something gross tasting. There are a couple patients who do like the supplement drinks so I will give it to them.

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