Dirty little secrets to managing LTC

[Kashia]

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.

[JB2007, ASN, RN]

JenniferSews, How on Earth do they expect the day shift to get it all done then? We are in the process of making major changes in how things are done at my facility and I think even more will be taken off of 3rd shift and added to day shift. Things such as nose sprays and eye gtts ect will be added on to the 0900 med pass. As it is now it takes every minute to pass the meds how they are to be passed within the time allowed.

I do my job and I do it correctly, but if anymore gets added onto my reponsiblities I am not sure if it will be done safely. That is where I draw the line. I will not risk lives.

[Forever Sunshine, ASN, RN]

JenniferSews, How on Earth do they expect the day shift to get it all done then? We are in the process of making major changes in how things are done at my facility and I think even more will be taken off of 3rd shift and added to day shift. Things such as nose sprays and eye gtts ect will be added on to the 0900 med pass. As it is now it takes every minute to pass the meds how they are to be passed within the time allowed.

I do my job and I do it correctly, but if anymore gets added onto my reponsiblities I am not sure if it will be done safely. That is where I draw the line. I will not risk lives.

I always go over the allowed time. Its just not possible to get 50 patients their pills in 2 hours. Thats 2.4 minutes per patient. If I have 25 patients which I have most of the time...thats 4.8 minutes per patient.

I will pass meds as long as it takes me to get every patient even if it takes me all shift to do(which it does when I have 50 patients..and I don't stop... not even to use the bathroom. I am not going to make a mistake that will harm my patient just so I can get pills passed in 2 hour time frame.

[TheCommuter, BSN, RN]

I currently have 31 residents with a medication aide that administers all of the oral pills, eye drops, patches, and nasal sprays to the patients. Since I'm the licensed nurse, I do wound care, topical creams, inhalers, nebulizer treatments, finger stick blood sugars, feeding tubes, and injections.

I love this set-up because it enables me to have more time for charting, paperwork, breaks, etc. If a resident circles the drain and needs to be sent to the ER, I can assess them and send them out without falling behind, because the medication aide is passing the bulk of the medications.

People can bad-mouth medication aides all they want, but I love working with them.

[ellen 12]

A medication aide sounds wonderful.

Last job - I was working mane shift giving 40 patients medications.

It is really hard whilst working sole RN to sign for all medications correctly when giving medications to this many patients. I get the drug to the right patient but working with this number of patients creates too much risk for error.

I have learned not to confront management on anything, it is just to easy for management to get rid of registered nurses who push for change by going to medication records and searching for mistakes in documentation.

Aged care is a poisonous system in my country and there are all sorts of pressures that keep staff who strive for better systems quiet and subdued.

I like aged care, I am good at my job but twice in two different job settings - after challenging management - my practice has immediately become an issue.

My interest in nursing is end of life care and this is where I want to work.

[nursenow]

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.

Mainly, I was reffering to MAR signing errors (not initialing...) I would have to see it to believe it if someone told me they never made those types of errors. I have made one med administration error(to my knowledge) as a new grad and the appropriate response/steps were taken by the facility.(that didn't include firing me thankfully)

I have to agree that if you can pass meds for 44 patients on time without any shortcuts that is a good thing but I am trying to remember if I have actually seen someone do that in 2 hours and do finger sticks on time. I am sure I have but not often. Now I remember. the only time you have 44 patients in California is NOCS when most of the people are sleeping except at 0600 when you are passing out Prilosec type meds. That is definatly do-able and do-able by the book easily..

[Pegasus65]

Inhalers, nose sprays, and eyedrops etc. are all done on the 9 a.m. med pass at the facility I work for. I work the weekend Baylor shift. At this time there are 32 residents. I wish I could say it is possible for me to complete the med pass in the allotted two hours, but so far it hasn't happened. There are too many interruptions. While I try to go as fast as possible I would rather be accurate. I have been told that if I worked more days during the week I would be faster. Actually what I would probably be is OUT of there lol.

Have a great day!

[southernbeegirl, BSN, RN]

I used to work the floor in an ICF facility and had 48 pts. the only way i could get all the meds done near on time was that i had memorized a lot of them because it was an ICF hall with few new orders. i also had to sign my mars after the pass along with the narcotic book. luckily, not much charting since it was ICF.

fast forward to my present job. our SNF nurses have 15-20 pts. SNF pts require so much more care than they used to. my nurses do the meds and the charting, i take off all the orders, call all the docs, do labs, IVs, field complaints, do all the transfers, do incident reports for the nurses if they need me to and anything else that comes up because the only thing my nurses have time for is the meds and charting. it takes all of us to get it all done.

of course we all take our own shortcuts. one thing i'd never take a shortcut on would be anything to do with narcotics. i had my license on probation for being a drug addict. i met the BON. believe me, don't take shortcuts on your narcs because you do NOT want to have to meet the BON. so i sign as i go on these or at the very least make sure i keep a list so i sign all out properly.

i dont skimp on supplements either. i know they are a pain in the rear, but look at their labs, they need those supplements desperately. i try to stock my cart up before i hit the floor, with puddings, supplements, juices. it just helps me to get it all prepared before i hit the floor.

but we all do things differently. they way i look at it, there are many ways to skin a cat, as long as we get done near the allotted time and didnt kill anyone, we did good, lol

[Forever Sunshine, ASN, RN]

I used to work the floor in an ICF facility and had 48 pts. the only way i could get all the meds done near on time was that i had memorized a lot of them because it was an ICF hall with few new orders. i also had to sign my mars after the pass along with the narcotic book. luckily, not much charting since it was ICF.

fast forward to my present job. our SNF nurses have 15-20 pts. SNF pts require so much more care than they used to. my nurses do the meds and the charting, i take off all the orders, call all the docs, do labs, IVs, field complaints, do all the transfers, do incident reports for the nurses if they need me to and anything else that comes up because the only thing my nurses have time for is the meds and charting. it takes all of us to get it all done.

of course we all take our own shortcuts. one thing i'd never take a shortcut on would be anything to do with narcotics. i had my license on probation for being a drug addict. i met the BON. believe me, don't take shortcuts on your narcs because you do NOT want to have to meet the BON. so i sign as i go on these or at the very least make sure i keep a list so i sign all out properly.

i dont skimp on supplements either. i know they are a pain in the rear, but look at their labs, they need those supplements desperately. i try to stock my cart up before i hit the floor, with puddings, supplements, juices. it just helps me to get it all prepared before i hit the floor.

but we all do things differently. they way i look at it, there are many ways to skin a cat, as long as we get done near the allotted time and didnt kill anyone, we did good, lol

But if a patient refuses it or drinks only some of it... I don't make them drink the rest of it. Especially if they just ate dinner or are going to dinner soon. I am not going to overstuff them or make them full with supplement drinks. If they were at home would they be drinking them and spoiling their appetite?

[SuesquatchRN, BSN, RN]

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?

I have worked all three shifts and am currently on first.

I did change times on the 6 a.m. pass so that I could stagger them. Now, when I have a cart on days, I get the 8 a.m. pass done in two hours. It certainly helps that I know the residents. But do NOT take shortcuts. We had four nurses for four days in a row give someone the wrong metoprolol dose because they were popping from semi-memory - Yeah, here's her Toprol, pop - without actually checking the dose closely.

[NotFlo]

I currently have 31 residents with a medication aide that administers all of the oral pills, eye drops, patches, and nasal sprays to the patients. Since I'm the licensed nurse, I do wound care, topical creams, inhalers, nebulizer treatments, finger stick blood sugars, feeding tubes, and injections.

I love this set-up because it enables me to have more time for charting, paperwork, breaks, etc. If a resident circles the drain and needs to be sent to the ER, I can assess them and send them out without falling behind, because the medication aide is passing the bulk of the medications.

People can bad-mouth medication aides all they want, but I love working with them.

Wow sounds like a pretty good set-up to me. I don't even know what I'd do with myself if I wasn't chained to the med cart all day.

[NotFlo]

i dont skimp on supplements either. i know they are a pain in the rear, but look at their labs, they need those supplements desperately. i try to stock my cart up before i hit the floor, with puddings, supplements, juices. it just helps me to get it all prepared before i hit the floor.

I see the low albumins, wounds that require extra protein, etc. but it comes down to the patient. If they HATE the taste and I try mixing it into everything possible and try everything to get them to tolerate it and they wont, what am I supposed to do?

The nutritionist and unit manager see the labs and just keep adding supplements to satisfy documention requirements and prove that they did something. They don't think about how this patient already has poor PO intake, how we struggle all day just to get them to eat fifty percent of their meal and take thier pills and how they will refuse and refuse no matter what we do to get them to take the supplements.

I discharged a lady in her nineties the other day. It was my first time taking care of her (it was a new assignment for me). She had ordered a can of glucerna select AND and a can of pulmocare BID with lunch and dinner. This lady weighs all of 80 pounds. HOW the heck am I possible going to get two cans of stuff into her during or after her meals? It could take the entire time between lunch and dinner for her to take those supplements a sip at a time and the entire time between dinner and bedtime to get them down and she still probably wouldn't be able to finish them. I am required to document percentage taken on each.

I just wish there was more common sense used when ordering these things.

[CapeCodMermaid, RN]

I was a staff nurse on a 60 bed subacute unit...I mean true subacute. I had 30 patients of my own....all meds and treatments and charting....5-6 IVs, TPN, trachs, gtubes. I finished the pass within the allotted time every day. You make a system that works for you and stick to it. I didn't pre pour or presign. I did it by the book. If the patient took an extra bit to swallow the supplement or meds, I'd stand in the room and either get the room mate's meds ready or do some assessments...lung sounds, cognitive issues, check out those diabetic feet....I very rarely had to stay late. Did I stroll down the hall taking my time? Nope..I hit the floor running every day.