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.

[nursenow]

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?

The majority of what a nurse does in a LTC is pass meds. If you hire a couple med aids, why do you need a nurse? Just replace two out of three nurses with a med aid, pay them less, let the nurse do the charting/assessments and treatments and the facility profit goes up. I think people forget the primary goal of a nursing facility is to make a profit. That is why people start them/buy them/invest in them... A very quick way for a DON or Administrator to lose their job is not to make a profit for the facility owner/s. They may be providing an important service to the community but like any other business they are there to make a profit. On the other hand, I dont expect to see med aids in California replacing nurses during my lifetime for the same reason they are cutting back LVNs in hospitals. The nurse union is very strong and doesn't like the competition. I dont know about other states.

[Forever Sunshine, ASN, RN]

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!

Put yourself in the shoes of the patient here. Would you like to be taking .. colace, a multivitamin and tylenol at 4...then an hour later here comes the nurse with blood pressure pill and digoxin? I wouldn't be a very happy patient if I keep having to be interrupted to swallow more pills.

[bunsterj]

This sounds horrible. I am not familiar with LTC, but don't you also have to do a lot of paperwork (not Q shift, but perhaps weekly or so) for Medicare/Medicaid? It just sounds like the bulk of your time is tied up with meds..

[texasheat]

I don't think having med aides to do med pass takes the place of a nurse or trying to do away with nurses. In texas, medication aides are allowed to give meds including digoxin, coumadin and BP meds, they are not doing any type of patient assessments. In our facility our CMA are very good about reporting any abnormal vitals to charge nurse. Med pass does take up alot of a nurses time, this gives nurses time for svn, treatments,cbg and more hands on patient care for our patients. But I guess our facility is lucky that our Administrator and DON do stay on the floor and have a good report with the nursing staff. Not that I have anything against agency nurses but we have not had to use any agency nurse for a good few years. I personally have never done agency but I imagine it must be difficult to go to a different place all the time.

[tewdles, RN]

"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."

This might explain why some of my patients are almost hopelessly constipated and, therefore, uncomfortable in spite of comprehensive order sets to prevent and treat...

[toninurse]

SuequatchRN said, "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."

I agree with you. It's possible when you've had time to get to know the patient's routine and your CNA's. I worked on a rotating AM and PM shift on the same unit for 17 months and it took about half that time to get meds passed and everything done in the timeframe required. What I wasn't able to do was be compassionate with my patients; I worked with blinders on, trained the CNA's to be more responsible and not run to me everytime someone farted sideways, and I also asked for help...didn't always get it but knew when to ask. I wasn't able to ethically or morally be the nurse I thought I was. Needless to say I changed facilities because they didn't care that I felt like a "medication administration machine." LTC and SNF have a hard time holding onto nurses that never give up on doing the best job possible...and that's a shame.

[nursenow]

A very large part of a nurses job in LTC is med passes. If a med aid is doing that how does it NOT take away from the job a nurse?

[toninurse]

nursenow,

That's just it, an LTC/SNF RN has the same general responsibilities as any other RN, AND she/he works with a large group of people that have multiple chronic conditions, a massive amount of medications, and daily treatments from applying nystatin on ab folds and monitoring for skin breakdown to wound vacs and trach care...AND change of condition is usually subtle and vague. If she misses COC she's putting that patient, her license, and the facility in jeopardy. We rely on 2-4 nurse assistants that hopefully have the time and morals to report a COC or even the training and/or experience to notice. It shouldn't be "all about meds" but it IS all about meds which is why NH and SNF suffer the reputation they do. I love what I do and care deeply about the people that rely on me to do what's best for them...shame on me (and shame on the facility) that can't fit my responsibilities into an eight hour day. I continue to advocate for better working conditions for nurses in LTC.

[tewdles, RN]

A very large part of a nurses job in LTC is med passes. If a med aid is doing that how does it NOT take away from the job a nurse?

I don't wonk in LTC, but I did want to comment that part of what an RN does is delegate tasks to others in order to provide care for the group of people.

While we cannot replace a nurse with a med aid, we can utilize the training of a med aid to free the nurse to complete other "nursing" functions. They work as a team to provide the best care possible for the residents.

[nursenow]

If you take away over half the nurse's job by hiring med aids, there is no way nurses wont be laid off. There is not 8 hours of assessments/charting and Calmoseptine to put on red behinds to do on the typical shift. I have wound vacs, pin care and various wound treatments to do and at times I struggle to get everything done by the end of the shift but if I wasn't passing meds I could do them and all my charting in 3 1/2 hours. I don't see the owners letting me sit around for 4 1/2 hours. There is only so much "assessing" you can do on a shift. You can lay off several nurses, hire med aids and let the remaining nurses supervise the aids but in the end you still have fewer nurses. In California it doesn't matter because the state will never allow med aids to exist here.

[tewdles, RN]

I am sorry that over half of a given nursing job is nothing more than passing medications...most of us did not go to nursing school to spend the majority of the day passing routine, long term meds.

[nursenow]

I am sorry that over half of a given nursing job is nothing more than passing medications...most of us did not go to nursing school to spend the majority of the day passing routine, long term meds.

Unfortunately many jobs require it like many nursing jobs require sitting at a desk 8 hours a day. Others require many hours aday on the phone. Others require standing in front of a goup of people all day talking... I guess it depends on where in the field of nursing you work. If you choose a SNF/LTC, you are going to be passing meds many hours aday unless you are moved onto the office (MDS, DSD...) but don't be fooled into thinking that is not "real" nursing and not as important as other areas of nursing.