You just received a magic RN license in the mail last week. You are hired as the new Director of Nursing at a (fictional) nursing home on the outskirts of town called Pine Bluff Manor.
You arrive to take a tour of the facility, and find that it is in very bad shape. Morale among staff is extremely low, patient care is sub-standard, and place is filled with the stench of urine and feces. Here are the big issues that you will need to address as the new DON:
- The facility is infamous for poor patient care. Skin breakdown, falls, and pneumonia are very common. Staff at the local hospital have been overheard using the term "Pine Bluff" as an adjective for poor quality, and several residents have been transferred to other nursing homes by their families.
- The staff are just... yuck. Each shift is short one CNA, along with at least one call-out per day for obviously bogus reasons. Every last one of the staff smokes, and this translates into about one 15-minute smoke break per two hours for each caregiver. There are only two part-time RNs; the rest are per-diem because they can't find a job at the hospital. CNAs routinely yell at residents. The facility hasn't received a job application in five months, and the average CNA resigns after about six months.
- Aside from those general problems with staff, there are unique problems for each shift.
- Day shift is dominated by "bully" CNAs who think that the evening and night CNAs are idiots. Only a few bed baths are completed per shift, it takes two hours for breakfast to be finished, and residents are often left sitting in the dining room until lunch arrives. Residents are only changed once, when they are gotten up in the morning.
- Evening shift is generally careless. If residents are not laid down by day shift, they remain in their wheelchairs. Though passing snacks is on the evening shift checklist, this has not been done in three years. Dinner is quickly "force fed" to residents so that they can be put in bed as soon as possible. PM care consists of being changed and wiped down with a wet washcloth; no soaps or peri-cleanser are utilized. (You look at the bottles in the patients' rooms and find that most were purchased last year, yet are still full.) Residents only changed once. Fall mats only put down occasionally.
- Night shift likes to sleep. A lot. You find blankets and pillows in one of the supply closets close to the nurse's station. You talk to some AOA residents, and they claim that they are changed and repositioned only once. Some say that they are only repositioned and not changed. You find that the average time it takes for a call bell to be answered on night shift is two hours, assuming it is answered at all. Some CNAs deliberately put the call bell out of reach so that the residents can't ring. It is night shift's responsibility to get some residents up early, and with a little prodding around you find that these residents are dressed and in the dining room at about 0230-- three hours before they are to be woken up.
You leave Pine Bluff Manor and head home, completely overwhelmed by the challenges you face. Regardless, you decide to sit down and come up with a plan of action to improve the quality of the facility as a whole.
Good luck trying to find any $$ in my bank account. The wonderful US government got to it before you did.
I actually had a few ideas come to mind about how we could raise money for this little project, but both involved arson and insurance fraud and would result in possible jail time for multiple people. I guess that means they're not viable options. :)
I guess we'll all have to sit around and wait for our rich uncles to die before we can get this show on the road.
Well, this is something that I like to think about in my free time ((which is limited, but enjoyable)):
1) First, because there are no applications flying through the doors you would have to work with the staff that you currently have; so, in order to create a better home environment for the residents of this facility you would have to retrain the staff they way they should have been trained in the first place ((it's a lot of slacking that was passed on over time that created the facility the way it is, I bet at one time it was considered a great place to be sent to)). At this retraining service you, as the DON, would have to set some basic rules ((slacking will not be tolerated, 3 strikes your out, no more than 2-3 call outs in the first 90 days of employment, and this fresh program((unless contagious, etc.)), and that you will have an open door policy((where employees, residents, and family members will be able to come to you with their concerns)). I think that you will get a lot of the things you need to fix from what the people of the facility have to say about the problems there.
2) I would have a family day where you can explain to the families what you are trying to do, and that this facility over time will become a place where quality, comfortable, friendly care will be provided.
3) Make the job fun ((it isn't always go to be fun on a day to day basis, but if you can make the staff want to come to work they are going to come to work and want to stay with the facility))
4) Raises are a bonus
5) Spring cleaning!!! Clean the place from head to toe, and find what you have and what you don't have. Use what you have until you have the money for what you don't have...but make it a priority to get the stuff that you don't have in a timely fashion ((because we all know the rumors that spread "they say they are going to get this and that, but it is never going to happen")).
6) Know the residents, staff, and family members. Smile and say hi!
7) Have recreation staff...make sure the residents are doing more than just sitting in their rooms sleeping or watching tv.
8) Create a home-like facility...."home is where the heart is" and for most a LTC is usually the last home a person has, so make sure everyone feels welcome and safe
It will take time and make sure everyone knows that it is going to take time become a strongly better facility, but until that day comes quality care should be priority--until the building can be remodeled to feel more home-like than hospital like....
If a facility cannot find anyone to work it, it will have to close or improve. But a brand new freshly licensed nurse is highly unlikely to affect change in this case, and she is starting her career in a very bad way, predisposing her to burnout.
The facility also probably needs to be reported, but does she really want to be working there while the investigation goes on.
The other issue, someone needs to investigate ratios. Do the personnel have adequate staff to lift, turn, reposition? And if the OP works there, has she thought of coming in on an off shift to assess and work with the staff, and investigate the claims.
Last but not least, I'd have a grand re-opening of the facility(complete with a new name)....
The facility that I'm working at now had their "grand re-opening" last fall and that place now changed into a new name. IDK their reason about it but probably b/c like you said "letting the people of the community know that we are a new & improved place that is focused on quality care."
Just my .02.. But I think that working with the existing CNA's would be the best place to start. Personally, (not that I have any valid experience at this sort of thing) I would have a 'come to jesus' meeting and just say, point blank, if you want to keep your job your going to have to step it up. If not, kick rocks. :)
Then I would devote as much time as possible with supervising/modeling routine care procedures out on the floor with the CNA's. Some of this could be delegated to the floor nurses, but unless they are on board 100% the RN would probably run into the same cycle as before. The hard part of the RN's job is going to be checking up on the CNA's work and calling them out when they make a mistake, offering to teach them the correct way or, for non compliance or repeat offenders, get rid of them. Hopefully that would light a fire under the existing CNA's butts to get them moving in the right direction... I also would do my best to make sure that I provided the equipment the CNA's needed on the floor and maybe get some incentive programs running for the CNA's who perform well. This might help the CNA's establish a trusting relationship with the new RN. I like the idea, too, of having a "Quality Assurance" inservice every once in awhile.. Customer service really is a huge part of what CNA's do, and if people cant provide good qualtiy care then they obviously dont belong there!
I would also start advertising for CNAs and LPNs to apply, making sure to mention that the LTCF is under 'new management' or is doing an 'internal make-over' or whatever. Once the patient care issues are cleared up, depending on the budget, I would start thinking about working on the building..
I work in a top tier facility that has very, very few issues with unsatisfying patient care.. It couldnt be a better place to work, actually. We all groan when we find out that the 'new hire' came from "insert name of nursing home with poor reputation here" because we know that we all spend the first few months breaking the bad habits they have formed there.
CoffeemateCNA
903 Posts
Good luck trying to find any $$ in my bank account. The wonderful US government got to it before you did.
I actually had a few ideas come to mind about how we could raise money for this little project, but both involved arson and insurance fraud and would result in possible jail time for multiple people. I guess that means they're not viable options. :)
I guess we'll all have to sit around and wait for our rich uncles to die before we can get this show on the road.