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.

[SuesquatchRN, BSN, RN]

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.

or we could hire more nurses to do what are and always have been nursing duties - such as passing meds.

why are we so willing to deprive other nurses of nursing jobs to save the facility a buck?

[texasheat]

I have been your replies and I still don't understand why any nurse would feel threatened by a CMA. I guess I don't see it. I am currently doing MDS but not too long ago I was RN Charge Nurse with 2 LVNs that split about 75-80 residents to do peg feedings, treatments, cbgs, svns, plus would also keep up with their odering of supplies, monthly summaries (10-12) each month plus labs needed to be collected, and assist with any falls, suctioning, or transfers to and from dialysis, hosp, etc. RN would report labs, keep up with appt and follow up plus admissions, readmissions, dialysis, assist MD with weekly rounds(such as podiatrist, psychiatrist, local mds). So passing oral meds was delegated to CMAs. As much as I see our nurses doing daily I can't imagine any of them upset because they are not passing meds! Maybe because we do 12 hr shifts makes a difference.

[tewdles, RN]

I would love it if LTCs would hire more nurses...

[CapeCodMermaid, RN]

Who is going to pay for them?

[nursenow]

The setup you described is not typical of most LTC/SNF. If the majority of a job is passing meds and a cma can do it for less $ per hour than an lvn/rn why keep the nurse around? If an lvn can do something for less $ than an rn why keep the rn around. if an rn an do something for less $ than an np why keep the np around... It is basic business for profit. It is not really a matter of what is best for everyone involved (except the owners). ltc is a business and the owner typically will want to run it in a fashion that will allow them to legaly maximize profits. I don't hold that against them. Just making an observation.

[tewdles, RN]

That same financial reasoning crosses the health care spectrum. Nurses are generally viewed as a necessary but expensive requirement.

[IowaKaren]

What I see where I work is the CMA replaces the nurse and then another nurse that has all her med's, tx's, charting, Dr.'s orders, etc etc just gets to pick up the CMA's work that they cannot preform so the nurse is actually burdened even heavier. It they would place CMA's to do ALL nurses meds, then it makes more sense so she can do the all the things a CMA cannot do but in the situations I have seen, it makes more work for the nurse and easier for error since the responsibilties haven't been altered for the good, just the cheaper.

[starletRN]

Unfortunately, all facilities are trying to save a buck and it just keeps getting worse with the economy. I was on med-surg at a hospital and they were always calling off our PCTs and we only had 2 for a 29 bed floor. This floor is heavy with total care patients. They expected the RNs to pass the meds with only a 30 hour window and do patient care, and do assessments and chart and...well, you get the picture.

That's especially fun when trying to give 9 am meds while being interrupted by physicians, family members calling to check on their loved ones (Yeah, the secretary wouldn't take a message. She'd page you constantly to come to the desk for a call and not tell you it's a family member) and various other issues. So, you can only imagine the things that get neglected.

It was sometimes 1130 before I was finished giving 0900 meds to 5-6 patients. By then it was time to do Accucheks and start on the noon meds. At that point its the snowball effect. I would be behind schedule for the rest of the day. I would work a 12 hour shift (Actually 14 hour day) and still think of all the things that didn't get done to my satisfaction as I was driving home.

No listening ear for a distraught family member or patient who is dealing with terminal illness. Teaching? What's that? Still wondering when I get to use some of that therapeutic communication they drilled into my head during NS. It's just sad.

[tewdles, RN]

starletRN...hang in there...it will get better, you will get faster and will develop scary skills in prioritization. Tip, schedule patient teaching for yourself if you can...rather than catching it when you have time, it is as important as passing a metformin in overall patient health behaviors and outcomes.

[starletRN]

starletRN...hang in there...it will get better, you will get faster and will develop scary skills in prioritization. Tip, schedule patient teaching for yourself if you can...rather than catching it when you have time, it is as important as passing a metformin in overall patient health behaviors and outcomes.

Thanks for the advice. It is much appreciated. :)

[shunkio]

It can be done efficiently and legally. I have been an LPN for three years and have worked in two different facilities and have also filled in and worked on every single shift imaginable. I have had anywhere from twenty to almost forty residents at any given time and have been able to manage the med pass with giving all meds on time all while answering call lights and toileting people. It is all a matter of what you are used to and able to handle. It does help if you know your residents well, how they take their meds, and what they like to take it with as well.

[MrsBradyMom]

I have 29 residents, 8 are diabetics. I work 7-3 and all of my diabetics gets accuchecks AC. Lantus is given at 9am along with Novolog/Novolin at each meal. Drops, sprays and patches are all given at 9am. We use accuflo med system and my 9 am med pass shows 384 pills to be given. The afternoon pass is 182 meds, not including supplements and snacks (that are considered meds). No way in heck am I getting that done on time. I start at 8am and finish at 11am....and I pat myself on the back. I don't take shortcuts, but I also don't kiss butt for them to take their pills. I work on a non-Alzheimers unit and these people know whether or not they want their meds. Half the time refusal=I want attention. I understand that and I hurt for you, but I just can't give you the attention you crave. Makes my heart break. I think it will be time to move on soon.