First impressions of LTC. How to give the best possible care?

dekatn · Aug 5, 2005

Where I work, it is totally unacceptable to sleep on the job I don't care how laid back LTC is supposed to be. Our DON got wind that one of the night shift nurses was sleeping, DON came into building in the middle of the night to check it out for herself. As for CNA's, our motto is, if you've got time to lean, you've got time to clean, meaning wheelchairs, or anything else that needs to be done. Not that you have to remain in constant motion the entire shift, but sleeping and lying around is not accepted. As for meds, to the best of my knowledge all meds are given as ordered, of course only the nurse that is responsible would know that for sure. MARS are checked daily each shift for blanks and corrective action taken, if it's a narc, the previous nurse is called in to clear it up. Same for I&O and VS. CNA's are responsible for obtaining VS at the beginning of each shift and reporting to nurse. If I&O's are not turned in at end of shift, staff is not allowed to leave the floor until they get them, even if the next shift is there and beginning to work already. You are right, sometimes we get busy and may overlook or forget occasionally, but not on a regular basis. I can imagine being new that this is difficult for you, it would be for me too. These residents deserve the best we have to give just like any other pt. When I worked nights, I always made a round q 2h just to make sure things were being done, I would also, stagger my rounds and not make them the same time q noc. As for the other nurse sleeping, I would wake her/him up, talk to the DON about it, if it continues. DON may not be aware of what is going on, if this is not the case, I wouldn't be comfortable working there. If I found out this is the norm, I would probably leave, because rocking the boat would probably get me no where fast and I wouldn't be willing to be involved when the mud starts sliding downhill, which eventually it will. You know, when it comes to state and federal guidelines, I have found that we must follow them in LTC the same as any other healthcare facility. Check your policy book. I did work for a privately owned facility at one time in my life where things were overlooked by management a lot more than in a corporate owned facility, which I work for now. They both have pro's and con's. I prefer the larger facility where things are more across the board and the rules aren't made up as you go along. The private facility was more like you describe. I personally couldn't deal with it.

dinkymouse · Aug 5, 2005

:no:In my nursing home sleeping on the job is grounds for immeadiate firing. Especially a nurse!! As said above there is always something to clean or stock. I don't care how ghetto it is the staff is way to lax.

milky · Aug 5, 2005

Dear Estrogen,

I would find another LTC to work at. "Ghetto" is certainly not acceptable. And sleeping on the job is out of the question, I can't believe the nurse who is orienting you would do such a thing!!! This is slightly off the subject but keep in mind Nursing Homes are by far the most federally regulated institutions in the country even more than nuclear power plants. Your charting will triple. But I still love it.!

estrogen · Aug 5, 2005

Dear Estrogen,
I would find another LTC to work at. "Ghetto" is certainly not acceptable. And sleeping on the job is out of the question, I can't believe the nurse who is orienting you would do such a thing!!! This is slightly off the subject but keep in mind Nursing Homes are by far the most federally regulated institutions in the country even more than nuclear power plants. Your charting will triple. But I still love it.!

Why is Ghetto not acceptable? What this nurse that said this NH is Ghetto ment, is that the people that are there are financially disadvantaged... I understand the objections to the laxness, but what's not acceptable about that?

....And yes, I agree that this particular nurse, that was orienting me, is a terrible nurse in more ways than one. But from what I can tell from the three days that I've been there, all the other nurses that I've encountered seemed professional. I'll be the onlu nurse on the ward during night shift, so I really won't have a chance to observe what other nurses are doing during their night shift duty. Should I even care??? ....as I asked during my original post, shouldn't "I" only care about what care is given to my residents during "MY" shift when "I" am on duty? ....or do my obligations somehow go beyond that?

....I'm affraid I might not be expressing myself very clearly here, but I'm just asking these questions to figure out what's the right thing to do for me personally. As I did somewhat indicate earlyer, a lot of things seem good about this place - for me personally (I really need stress reduction badly at this point of my life, the residents seem to be loved there and i like the fact that it's "ghetto" in the sense of the people being reather disadvantaged...)

But just how far should my concerns really go??

Bird2 · Aug 5, 2005

Why is Ghetto not acceptable? What this nurse that said this NH is Ghetto ment, is that the people that are there are financially disadvantaged... I understand the objections to the laxness, but what's not acceptable about that?
....And yes, I agree that this particular nurse, that was orienting me, is a terrible nurse in more ways than one. But from what I can tell from the three days that I've been there, all the other nurses that I've encountered seemed professional. I'll be the onlu nurse on the ward during night shift, so I really won't have a chance to observe what other nurses are doing during their night shift duty. Should I even care??? ....as I asked during my original post, shouldn't "I" only care about what care is given to my residents during "MY" shift when "I" am on duty? ....or do my obligations somehow go beyond that?
....I'm affraid I might not be expressing myself very clearly here, but I'm just asking these questions to figure out what's the right thing to do for me personally. As I did somewhat indicate earlyer, a lot of things seem good about this place - for me personally (I really need stress reduction badly at this point of my life, the residents seem to be loved there and i like the fact that it's "ghetto" in the sense of the people being reather disadvantaged...)
But just how far should my concerns really go??

First off congrats on your new job. Most LTC nurses really care about their jobs and most LTC's are nice. I am fortunate to work in a nice facility. The term ghetto is offensive. I am glad that you want to take care of the disadvantaged and that in itself tells me that you are a caring nurse. Dignity is a big issue in LTCs and those poor residents more than likely here the other nurse make the getto comments. The best way to put it all in perspective is this You are working in their home. Your job is to take care of all aspects of their care such as making sure their clothes fit, they are hydrated, their spiritual needs are met, there are no adverse reactions to meds etc... Good luck and I hope you find LTC as rewarding as I have.

dekatn · Aug 5, 2005

I'm sorry if I went overboard earlier, now that I understand you will be the only nurse on your shift, I will say, you are responsible for the care you give to the residents and what you do on your shift. You aren't responsible for what other nurses do or don't do on their shifts, unless it directly affects your ability to do your job, then I would say it is your responsiblity to alert the appropriate person in charge. Good luck on your new position, you sound like a really caring person and the residents will be lucky to have you there.

milky · Aug 6, 2005

estrogen,

forgive me for sounding judgemental. As long as you are happy at the LTC you are at and you can go to sleep at night knowing you did the best you can do that is all that counts. I am totally for helping the disadvantaged ....trust me I worked for public health in southside atlanta. Each and everyday I thanked my lucky stars I had a roof over my head and clothes on my back . I wanted to literally give every cent of my paycheck to some of these families some of which i did! But what i interpreted or "misinterpreted" that ghetto was a bad nursing home. Which I have seen a lot of too! I currently work for a large corporate LTC which is a very tightly run ship which I am very proud to be a part of. I wish you the very best in your current career please no hard feelings. We nurses are a rare and wonderful breed!!!

SitcomNurse, BSN, MSN, EdD, RN · Aug 6, 2005

After all, it's their home.
So my two questions are: 1) Are you other LTC nurses familiar with this? Is it "normal" for all Ltc facilities?
2) How should I "go with the flow" and enjoy the relaxed environment (after all stress reduction is why I left the hospital) and still be the best nurse one can be and ensure that on my shift the residents are receiving the best possible care?
Oh, and please don't get me wrong, I'm not doubting that at times it can get very stressfull and bussy in a LTC too, especially concidering the notorious staffing issues...

Okay, my 2 pennies... I am familiar with Nurses/ CNA's sleeping on the off shifts. On your break, you can do whatever you like. And, as long as the CNA's both agree, you can combine your whole break into one big sleep. Heck, I have had 2 CNA's, both exhausted, request to have 2 hrs each. The other awake person has to pick up that extra hour, and they dont overlap. It dosent bother me, as long as they understand; -If I need you, everyone comes.

I work in a LTC, state run, on a respiratory unit. We are not as slow as the rest of the building. That nurse who oriented you may love her patients, but she has no self respect, and no respect for you. That was your opportunity to LEARN!! C'mon!! Thats part of what we are taught in nursing school!! There is always an opportunity to teach! grrr...... :angryfire

The pace is slower, I know that. But that dosent mean the job you so should garnish less discipline. And it dosent mean you get to sleep on someone elses orientation. You want to work in an enviornment where you can keep your self respect, self esteem, and licence. Make that happen wherever you DO work, or find another place. I am sooo angry that that nurse slept. You have no idea.

I am an 11-7 RN, BSN. I have worked in dinky private facilities also..ghetto as you like, and sparkly clean $$$... Its who you are that makes the job what it is.

:angryfire

CapeCodMermaid, RN · Aug 6, 2005

No, not every SNF is like the one you're in. First off...we don't allow sleeping on duty-ever. Secondly, our sub-acute floor is just as busy (and busier than some I've seen) med-surg floors. Start at 7-get report-blood sugars and insulins for 12...pass trays...meds and treatments for 20, 3 discharges, 4 admits, 911 rescue for the guy who is 3 days post-op quadruple by-pass...hardly what anyone would call laid back. Even the 'long term' floor is hectic.

Daytonite, BSN, RN · Aug 6, 2005

....I'm affraid I might not be expressing myself very clearly here, but I'm just asking these questions to figure out what's the right thing to do for me personally. As I did somewhat indicate earlyer, a lot of things seem good about this place - for me personally (I really need stress reduction badly at this point of my life, the residents seem to be loved there and i like the fact that it's "ghetto" in the sense of the people being reather disadvantaged...)
But just how far should my concerns really go??

I think you are expressing yourself very clearly. Red flags are going up all around you and you are subconsciously recognizing it. This NH has problems. As someone said in an ealier post, this is why NHs are so regulated. You haven't even begun to find out how regulated and it has pretty much come from years and years of these kinds of behaviors going on. There is a different kind of stress in NHs. If you are a conscientious nurse I'm sure you will experience it soon. As a nurse in a NH you should also practice the same values and ethics you did in acute care--that should never change. Will you be able to deal with the frustration of thinking that you are putting in 100% of your effort into this job while some of the others around you barely contribute? I think that that may become an issue for you eventually.

I've worked in a number of nursing homes over the years, often as a second job and more recently as full time employment. Vital signs not getting done, people sleeping on the job and the uncompleted paperwork occurring consistently are unacceptable. This is due to poor management and supervision. I found myself working with another RN who was not giving patients their medications, making up glucometer results and sleeping (according to the aides working with her). When the DON seemed to ignore our complaints about her, several of us literally flooded the DON with documentation (because that's what you have to do) on this woman's behavior until the DON was forced to confront this nurse who promptly quit. The nurse was more miffed that the other nurses were questioning her "skills" and announced that she couldn't work with people like that. Can you imagine that? I never knew that failing to give medication, making up blood sugar results and charting them and sleeping on the job were skills. You see, you learn something new everyday. (All right, I'm being cynical.)

You will hone different nursing skills in the NH. One will be your observation skills. Elderly patients can't always tell you when they are hurting or something isn't feeling quite right. You will truly learn the meaning of being a patient advocate in a NH. You will learn that you must speak up for them because they cannot do it themselves. You will learn to supervise and manage the nursing assistants because they shouldn't be sleeping. There is ALWAYS something to do. You will get very good at tracking down doctors--some of them ignore nursing home nurses a little more than they should. Are you aware of the power you have to influence the ways things are done in a smaller work place like this NH? You have an opportunity to make a difference and affect the way nursing care is delievered in this NH, something you had very little input with in the acute hospital. And, if you don't like paperwork get out now because EVERYTHING is to be documented. Because NHs receive a good deal of reimbursement from governmental payers (Medicare and Medicaid) the accreditation processes and legislation have stepped in to put some control on what goes on in NHs. I'm surprised the MDS nurse hasn't sat you down to explain what she needs to see charted so she can complete her quarterly reports to CMS (Medicare).

I'm sorry if I sound kind of negative, but I think you should be prepared for some of the negative stuff you are going to experience. But, by all means, go in there with a positive attitude and all gangbusters. The NHs are a place to really use the basic nursing skills you learned in school as you will see. You will get to really know a lot of your patients which is something that can't always occur in the acute hospital. And, please, talk with the patients when you can, learn about them and their personalities, and do some basic psychology. Remember to respect that the NH is their "home". Don't compromise your practice. If you see something that is wrong (sleeping on the job, not charting medication being given, not charting on falls) please do something about it. That is the only way NHs are going to improve and attract better nurses. There is nothing easy about working in a NH. You will work as hard as you did in the acute hospital, believe me. I hope you hang in there and bring your best into your situation.

estrogen · Aug 6, 2005

I'm sorry if I sound kind of negative, but I think you should be prepared for some of the negative stuff you are going to experience. But, by all means, go in there with a positive attitude and all gangbusters. The NHs are a place to really use the basic nursing skills you learned in school as you will see. You will get to really know a lot of your patients which is something that can't always occur in the acute hospital. And, please, talk with the patients when you can, learn about them and their personalities, and do some basic psychology. Remember to respect that the NH is their "home". Don't compromise your practice. If you see something that is wrong (sleeping on the job, not charting medication being given, not charting on falls) please do something about it. That is the only way NHs are going to improve and attract better nurses. There is nothing easy about working in a NH. You will work as hard as you did in the acute hospital, believe me. I hope you hang in there and bring your best into your situation.

I don't think you sound negative at all. You sound constructive. Thanks fro the great post. I appreciate the advice. :)