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.

[southernbeegirl, BSN, RN]

we used to put the supplements on the supper trays. they didnt drink them. we started giving them out at med passes. we do 3-4 oz. with each med pass. we give that before the water and it's usually easy to get it in them then. we also use something called Prostat. have yall tried that? concentrated protien. they take 30cc only. but i hear it tastes horrible.

but when you have something that has never had a big appetite, never ate good, then all we can do is try. we get a good plan of care together and we try. we keep trying until we can say "well that aint working" and we try something else. all we can do is chart, chart, chart if they still wont drink them no matter what. but at least we tried, right?

[Nascar nurse, ASN, RN]

Someone said something about the little ole ladies that just sip... it really is something to consider. I'm not a petite lady by any stretch of the imagination, but even in my 40's and even with my beloved pop or coffee, I am just a sipper. I often take four hours to drink one can of pop.

The future nurses will hate me & think I am just being difficult when it takes me forever to drink the 4 oz of ensure - (not that I will probably ever have weight loss concerns :)).

[nursenow]

we used to put the supplements on the supper trays. they didnt drink them. we started giving them out at med passes. we do 3-4 oz. with each med pass. we give that before the water and it's usually easy to get it in them then. we also use something called Prostat. have yall tried that? concentrated protien. they take 30cc only. but i hear it tastes horrible.

but when you have something that has never had a big appetite, never ate good, then all we can do is try. we get a good plan of care together and we try. we keep trying until we can say "well that aint working" and we try something else. all we can do is chart, chart, chart if they still wont drink them no matter what. but at least we tried, right?

We give prostat and similiar supplements but can only do it with an MD order. We mostly give it to people recovering from wounds, sores, broken bones and the like for extra protein but the order is never open ended. The MD gives an order for 30 days or even just a couple weeks bid. For the patients that dont like the taste, they actually have alot of different flavors. I have tasted a couple out of curiosity and they weren't bad. (the original prostat tastes REALLY BAD!!) One way to give it if they wont take it is to mix it with their flavored drinks and they dont even know it.(technicaly illegal) Normaly where I work the Dietitian(spelling?) initiates the order wlith the MD.

[Forever Sunshine, ASN, RN]

We give prostat and similiar supplements but can only do it with an MD order. We mostly give it to people recovering from wounds, sores, broken bones and the like for extra protein but the order is never open ended. The MD gives an order for 30 days or even just a couple weeks bid. For the patients that dont like the taste, they actually have alot of different flavors. I have tasted a couple out of curiosity and they weren't bad. (the original prostat tastes REALLY BAD!!) One way to give it if they wont take it is to mix it with their flavored drinks and they dont even know it.(technicaly illegal) Normaly where I work the Dietitian(spelling?) initiates the order wlith the MD.

If they have extra protein ordered .... I will mix it together with the calorie supplement. It becomes thick, doesn't smell as nasty and the patients tell me it actually tastes good. Anyway you can get them to drink the stuff.

Theres this one LOL who i give this to and let her sip it as she wants. But she takes two sips.. puts it back down and then every time I walk past her I hand it to her and she says "oh why thank you so much.. *sips* oh this is delicious thank you"..

[TrickieTam]

I worked a facility that had two floors and each one had 54 residents each. I was upstairs and my supervisor was downstairs. I had 29 diabetics who each got fingersticks and my 3 cna's would get them for me in the mornings. I also had 8 tube feeders, 4 of them bolus. Oh and I had 2 trach residents who needed constant suctioning!! I worked there for 2 weeks and walked out because I was not Superwoman!

[VivaLasViejas, ASN, 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.

Me too, but maybe that's because we have such great ones where I work. They know their stuff, ask appropriate questions, and stay within their scope of practice.

I have pretty much the same set-up as Commuter, and it's very workable 95% of the time. Speaking from a former management perspective, this arrangement is the best use of licensed nursing time; speaking from a floor-nurse perspective, it makes the best use of my skills and allows me to complete my work in the hours allotted (unless, of course, it's a crazy shift). Yes, I do pass some meds, but the rest of my time is focused on wound care, assessments, tube feedings, charting, and the million and one other things only a NURSE can (or should) do. Even on the long-term care unit where I work, emergencies and other challenging situations do arise, and it's nice to have the time to deal with them and document them properly.

[nursinger]

I worked a facility that had two floors and each one had 54 residents each. I was upstairs and my supervisor was downstairs. I had 29 diabetics who each got fingersticks and my 3 cna's would get them for me in the mornings. I also had 8 tube feeders, 4 of them bolus. Oh and I had 2 trach residents who needed constant suctioning!! I worked there for 2 weeks and walked out because I was not Superwoman!

Good for you! :yeah:I would have left also. That's pure insanity!

[Kashia, ASN, LVN]

I really like the idea of medication aids! In California it is not an approved occupation as yet. But I can really see the benefits.

I would love to work in a facility that had this arrangement! Then I may not consider to leave what I am doing, which quite frankly is insane...agency nurse, different facilities...yesterday I actually broke down and cried! I have never done that.

The aids refused to help do vitals on my BP meds patients. Amongst many other things...

After reading all these posts I do see it is a relative situation. It just depends on

where when how and who. It can be manageable and legal guidelines followed.

[SuesquatchRN, BSN, RN]

I really like the idea of medication aids!

Why do people like the idea of one less licensed person on the floor? It's just another way to lessen what we do and know, to save money, to eliminate nurses, and to short-change care.

[217shana]

If possible I would get the patches changed to 6am as well as the nose sprays and eye gtts. I have worked at a facility where we placed the tube feeders on a 6am daily med pass and BID was given at 6am & 6pm. Talk with the doctor and see if some patients would not benefit from long acting medication or sustained release. Talk with the pharmacy when they come in. It truly does not make sense to give a multivitamin to every patient in a nursing home especially those that are obese. One of the other things you can do if Tylenol is ordered every four hours see if you can get the tylenol arthritis which is given every 8 hours. If the patient is up early and there is no contraindication see if they will agree to have their meds changed to 6am for the daily dose. Fingersticks could be done at 6:00 am or 6:30 am and usually twice a day. Performing a fingerstick 4 times a day is usually for acute care settings. Look and see if the blood sugars are usually normal and see if the MD might decrease them from daily to twice weekly. In my area there are nurses that give medication to 50 patients when they work alone.

[Kashia, ASN, LVN]

Why do people like the idea of one less licensed person on the floor? It's just another way to lessen what we do and know, to save money, to eliminate nurses, and to short-change care.

Well I actually feel the same as you. But in LTC the bigger picture is what is happening now, at least in CA, is not working. If I consider all, the one thing medication aids could do is pass some of the meds. Supplements, vitamins, minerals, colace,

bowel care stuff. many of the meds are routine and it is not rocket science to pop them out of a bubble.

Perhaps some things, like Dig, Coumadin, BP meds leave to nurse...it is just a consideration after I worked an impossible 14 hr shift with no break. What is "safe" about that? A license does not supplement food or a break. A fatigued nurse can only be half (or less) as safe as a rested medication aid- I consider this!

I am not advocating less quality, but as facilities are not caring about quality and in CA they are re designing staff patient ratio's I am open minded to possible solutions. I mean the ideal solution is to reduce patient load, to have more nurses.

I do not see that happening, in fact I am seeing the opposite here. And it is a rapid changeover to higher patient loads, like in the last couple weeks. I would like to know why this is happening?

Someone just posted part of article from Sac Bee , it is on front page here in articles, how even though nursing homes have received a lot of gov money, facilities are crunching staff.

So yes I am open minded to possible solutions to what is becoming a worsening situation. And perhaps considering med aids is one possible solution?

[texasheat]

I have been working at a LTC/SNF for about two years now. And yes there are alot of shortcuts that might be needed to finish with your daily load. But taking shortcuts is one thing and not giving out the meds is a totally different thing. And those who see it and don't report are just as guilty. That is why LTC get such bad reputations because they have nurses or staff that don't care or have any pride in what they do. I guess this is a tough subject for me since I do enjoy my work and we have a good staff. Our facility does employ CMA to help out with day and some evening med passes. AND NO I DON'T THINK 'MEMBERIZING' MEDS IS ANY SAFER EITHER!