Nursing Home Supervisor challenges with WOUND CARE - page 2

Hello everyone, I'm in SERIOUS need of advice, please. I started a nursing home supervisor job in the summer of 2017 and, even though I've been a charge nurse in my 22+ year career, this... Read More

  1. by   ProperlySeasoned
    Sounds like there is a culture of pre charting. That needs to be addressed. I agree with the nurses that said they "forgot." That's the danger of charting something you have not done yet. Here's a question: Do the LPN's know how to do a propper dressing change? Do they have the supplies? Do they have enough time in the day to do so?
  2. by   djh123
    No suggestions really, but 'I feel your pain'. At my previous LTC/rehab job, I had 2 problems similar to yours. CNA's who wouldn't put someone's padded boots on, or wouldn't turn them, or didn't put barrier cream on a sensitive area - and/or in some cases, residents would refuse boots, or to be turned. And then yes, sometimes I'd follow a nurse or two who were supposed to have done so-and-so's wound on day shift but hadn't.

    Akin to an Avon lady jokingly telling my ex one time that 'It ain't gonna do you no good in the bottle', wound care ain't gonna work if we don't DO it.
  3. by   Have Nurse
    Quote from meanmaryjean
    Someone might need to lose their job. Because clearly the "corrective action" is neither.
    That's what I'm thinking, not to mention reporting the L.P.N.s to the Board for falsifying records which incidently, is illegal. Put some teeth in it.
  4. by   Caprica6
    It might be time for a surprise visit from your state ombudsman or health department...
  5. by   K+MgSO4
    Part of my management approach is to ensure that the staff have all the supplies to do their job. Do yours have dressing trollies, correct dressings and enough of them, sterile gloves in the correct size etc?
    Do they need leg lifters to attach to the hoist to lift a leg for a heel dressing if the patient can't lie prone for the dressing?
  6. by   Crush
    Quote from meanmaryjean
    Someone might need to lose their job. Because clearly the "corrective action" is neither.
    Although I hate for someone to lose their job, in this case there has been corrective actions. The catch is the facilities policy of it goes away after a year and I imagine staff knows this. I am happy to read the OP does have their supervisors support though.

    Quote from Have Nurse
    That's what I'm thinking, not to mention reporting the L.P.N.s to the Board for falsifying records which incidently, is illegal. Put some teeth in it.
    I still think consistency is key here but I sure hope that this improves soon. Maybe it is time to rethink the timeline for those warnings to "reset".

    I totally agree with you OP, "Where are these people's conscience?"
  7. by   cyc0sys
    I never heard of a Nursing Home Supervisor. It sounds to me like an administrative title so that might be part of your problem. Also, if you've never worked the floor in an LTC as nurse, I wouldn't expect a lot of respect or compliance. I've seen too many 'seasoned' hospital RNs walk into the LTC only to turn around and walk right back out because they don't understand the culture or worst, though it was going to be some cake walk.

    I wouldn't go around threatening people's license unless you have enough evidence to bury them criminally and enough money to defend yourself in court. These are the people who know where all of 'the bodies are buried' (think thousands of pages of regulations that are broken everyday by facility) and probably aren't purposely doing wrong but have no recourse.

    That being said, I've never seen an LTC properly staffed, budgeted and supplied unless it was private pay and didn't accept medicare or medicaid. Maybe you work in one of these magical mythical unicorn filled places, I don't know.

    Remember, it's just as easy for anyone to call state or the ombudsman and report the facility for medical negligence.

    I don't worry about those things myself. I understand the terms: turning state's evidence, immunity, witness for the prosecution, and defamation tort law.

    Don't do anything your career can't handle.
  8. by   OldDude
    Are you the DON of this facility?
  9. by   Neats
    Being a manager is not all sit in office and play, being a good manager is hard. The hardest is follow through. It is easy to discuss what needs to be completed, to discuss a policy/regulation. What is hard is to go back and hold people accountable for what you have clearly instructed them to do. I was a traveling Licensed Nursing Home Administrator and Director of Nursing for over 20 years. What ever facility I went into I was a hard *** from the get go. No wriggle room for anyone and I worked long hours, mostly doing admin stuff and then on the floor making sure people were doing what they were suppose to be doing, reviewing documentation...once things became better I would let up. With that said it sounds like you need some mentoring.

    Because you are established in this facility as the nurse who communicates and wants things done (you come from a good heart) but it appears you do not use your authority or you have the responsibility without the authority and now you need to take things away which is more difficult than being a hard *** but it can be done. I would have my days go something like this for at least one month:

    If a shift starts at 0700 hrs I would get to the facility at 0530 hrs.
    1. Do a round of the facility say good morning, is there any concerns... let this last only 20 mins-30 mins dependent on the facility size.
    2. Review the 24 hour report (it may not be completed for night shift and this is OK on your rounds you have some what of an ideal of what is going on. Review for not greater than 20 mins.
    3. Look at the schedule and see who is on, I would do the assignments for all nursing staff (again you know what is going on because you looked at 24 hour report and asked questions to NOC staff). Take the time for at least one hour for this task because this includes break times/wound/shower/meals/who will take the admits if any for the day...after the initial 2 times you have done this it will get easier and will not take as much time. When staff complained let them know that these issues have been discussed, no changes occurred that improved with the needed regulation (although you appreciated everyone's help) and now you have to take a different path in order to place us back into regulation. You should have each staff name with a check list on their tasks you need to keep. Or if you will each task should have a staff name who is responsible for the completion. Example
    There are 4 tasks that need to be completed

    3-1. Wound care dressing changes for XX patient need to be completed 1500 hrs (5 in AM and 3 in in afternoon all done before 4 PM. RN Jones is responsible for this today to let the unit nurses know they have dressing changes to do today. and will give you a list of what dressing changes occurred and what nurse was assigned the dressing change. So in short RN Jones is placed in charge with the wound care completion today, they will report to you about the wound care status. You have the chance to ask why it has not been completed, if they say I don't know then you must take RN Jones with you hunt down the nurse responsible for the actual wound care changes and ask if there are any problems. If so then the 3 of you can attempt to solve them.

    3-2. BP need to be completed by 0800 hrs Sue Smith NA-C is responsible for seeing that all needed BP results are provided to licensed nurses. This one is easy all must be completed by specific time so the nurse can give medication if not done then write up the NA-C who was suppose to get it done unless an emergency.
    3-3. Any Admitting completion is handed to Joe Flow RN who will provide you with the completed paper work 30 mins before end of shift. Again admission should be completed UPON ADMISSION this is part of patient safety and part of keeping you license as a nurse squeaky clean. You need to know what you have.
    3-4. Shower's assigned Stephanie NA-C will be responsible for providing to each unit licensed staff member the names and completed shower check list that includes any concerns by 3 PM. Again if not completed then write up unless there is a good reason.

    4. I would leave by 7 PM and I always came in a few times on NOC shift for the whole shift. Long days but effective and productive.

    So once you have this what you do next is every 2 hours you go back and check on your designated nursing staff to see how they are doing with their task assignments and to see if any of the assignments have been completed. If they completed tasks them out on your list and go onto the next 2 hours and do the same. Is this micro managing yes and no. You have made people responsible for a portion of what needs to get completed ether in the form of them doing this themselves or to delegate this. Even the NA-C can do this. If it does not get completed go back to that assigned person and ask why it was not completed.

    Since you are going back to these people you delegated tasks to every 2 hours after the second time they generally know they need to get it done. It is OK to say to them you know there are 8 showers today and it is 10 AM. A shower takes time and this needs to get done, I am expecting at least 4 showers within the next 2 hours when I come and ask you again. I am not trying to be mean just want us to be in regulation. Do not discuss anything else...just let them know I think you are resourceful and will report back and show me the documented showers that have been completed. When you talk to your assigned staff I would let them know I need you to write down the names of who you spoke to and what you delegated them to do and time you spoke to them.

    If the work was not completed then I would go directly to that person WITH Sue, Joe, Stephanie, RN Jones to ask why it was not completed. If they do not have a great excuse i.e. we had a patient expire, this resident was running a fever, wound care was completed last NOC because the dressing came off...If no good excuse I would ask to speak to that employee who was suppose to do the task alone in private and write up a little discussion was made, give them a copy of the policy/regulation (I even give out F tag verbiage). Excuses are easy, people can rationalize anything. Keep in mind once you allow the excuses you will have no control over your environment. I am forever saying to employees make it work. This may mean your favorite person who you like to go to lunch with you will not be able to but you both get a lunch.

    So basically your whole day is to be a babysitter. This works, you can do this in a dignified manner, in a respectful manner. It sends a clear message that work is work and we must comply with regulations and policies. You will have complaints, you will have people put their resignation in, you may in the long run have a wonderful staff (you more than likely already do) that now know a clear working environment that is in compliance, that can handle hiccups without too much interference, and that is providing great care. The residents will be happier and so will the staff in the long run.
    Lastly I would have copies of common policies, F Tags, regulations ion my desk so when I do speak to an employee I always say at the end I look forward to improving our facility with you, here is the regulation, policy F Tag that shows how we must be in compliance and why we are suppose to do things this way. I look forward to you teaching this to to others.

    Hope this helps you to be a better manager.
  10. by   nursej22
    I agree with doing a deeper assessment of the why the dressings aren't getting done, getting the past "I forgot, I'll do better." Is it time, supplies, knowledge, prioritization?

    Have you tried to schedule sessions where you and the LPN do the dressings together? Maybe you establish a routine that you will watch x number of dressings each week. They have to do it if you are there right? And this would give you a good idea of work flow. And you heap on lots of praise when a job is done well. Remember to praise in public, and correct in private. And use the "onion sandwich" delivery. Say something positive, say what could be better, and then follow with a positive. "Jane, I see that you have a great rapport with the CNAs. I have noticed that Mrs. X does not have her wedge in place. Please encourage your team to use them every time. I know that we all want to avoid pressure ulcers."

    How about some motivational interviewing? Do staff feel that dressings are important? Do they understand the benefits, and risks when they aren't done? To the patient I mean, not just the threat of a warning. Do you have any success stories about healing a bad wound? At my first job we had a person come in the a stage 4, almost completely closed with good turning and wet to dry dressings. The staff was so proud of what they were able to achieve.

    Obviously the write up approach is not working. I personally would come at this from a team approach and show the staff that you value them and believe that they can deliver excellent care.
  11. by   Davey Do
    I truly appreciate your plight and endeavors to assure quality care is provided to those you serve, Marie0304!

    This thread could be interpreted as a data gathering/brainstorming process in dealing with the problem of skin and wound care goals not being met. There was mention of sanctions toward those not fulfilling their duties. This is a viable option and can change a culture only if the reasons for the sanction is made clear: Resident neglect is a form of abuse. Sanctions are not given for punishment, they are given to assure quality care.

    There are but two options these employees have: Provide quality care and documentation or deal with the ramifications of their actions or inactions.

    Another point: I do not allow a patient to wallow in their waste. Partially because I know that providing hygienic measures is my responsibility. Another reason is because I was incontinent of stool as a bedridden patient after an MVA when I was 19 years old and know what it feels like. I want no other individual to have to experience the physical and emotional discomfort tat I went through, so I am Johnny-on-the-Spot!

    You mentioned, Marie0304, that you had regular inservices with the staff. Here's an idea: We had an inservice on the geriatric psych unit where we had to experience what bedridden wheelchair bound patients experience in order to gain empathy for some things our patients have to deal with. For example, we had to sit in a wheelchair on a small rock and not change our position. Sort of a "How would you like it if this happened to you?" sort of thing.

    Once again, I admire your actions in wanting to provide quality care to those you serve and your endeavors in relaying the importance to your staff, Marie0304.

    Good luck and the very best to you!
  12. by   caffeinatednurse
    I worked in a supervisory role (meaning I was the only RN in the building during the 3-11p shift most nights) in LTC, prior to switching back to acute care. More often than not, I was the one making the schedule for the week ahead. So if we were short staffed, it meant that I was making mistakes somewhere. I used to schedule a "treatment" nurse for as many nights as we could afford. An extra RN or LPN who would do all of the treatments, skin assessments, dressing changes. This took it off of the shoulders of the hall nurse. We also had CNA II's who could help with treatments and dressing changes (but not assessments). Just something to ponder.

    Even then, I still had problems with staffing from time to time. Whenever I encountered staff that I noticed were purposefully not doing their jobs, I would "rotate" them off of "their" favorite hall (most LTC nurses have one, believe it or not) for a week or two.
  13. by   NutmeggeRN
    Quote from cyc0sys
    That being said, I've never seen an LTC properly staffed, budgeted and supplied unless it was private pay and didn't accept medicare or medicaid. Maybe you work in one of these magical mythical unicorn filled places, I don't know.
    Ha!! Private pay facilities are just as short staffed....