Then residents who were alert and oriented were saying they weren't getting their pain medications. The CMA would always insist that the pain meds were given. Well one weekend when a nuse was working the med cart and was swapping out the sharps containers and noticed that it wasn't full of used needles, it was chock full of pills. We figured out how she was getting through the med pass so quickly, she was popping them and putting them in the sharps container, and she would pocket the narcotics. We notified the DON, but not a single thing was done. And she actually got smart and would give the very few residents who were alert and oriented all of their meds, but she continued to pop the meds of the residents with dementia but instead of putting them in the sharps container, she would throw them in the trash and then empty the trash well before shift change thinking nobody would notice, but we did notice and reported her to the DON, once again nothing was done.

One day one of my residents with a history of epilepsy had a grand Mal seizure in the dining hall. I notified the doctor, the doctor asked how much Dilantin he was on, so I told him, and the doctor stated "wow he is on the max dose of dilantin. Get a Stat dilantin level." Guess what his dilantin level was? Zero. He wasn't getting his dilantin (real shocker, nobody was getting their meds). I felt like my license was at risk and the DON refused to take action against the CMA so I resigned.

I got a job at another 172 bed LTC/SNF. They told me that the SNF portion is 20 beds, so they have 2 nurses on that hall, each nurse gets 10 skilled residents and then in addition you split a LTC hall and took 10 LTC residents. So essentially you have 20 residents which is not too bad for the 3-11 shift. In July this independently owned LTC/SNF was bought out by a large corporation who like all corporations are focused on the profits, we were told that we would be getting a lot more skilled residents and that they were actually turning one of the LTC halls into another SNF hall. They also told us we would be getting higher acuity residents with TPN, wound vacs, pressure ulcers, bipaps, etc. What they didn't tell us was that they were taking one of the nurses away. So now you have 1 nurse for 20 high acuity skilled patients and you also have 20 LTC residents. The nurse that was working day shift when they made the change said "this is not safe" and quit. They brought a nurse from one of the other LTC halls to work and she made it about 2 months and then quit. They asked me if I would go to 7-3 for a $5 an hour pay raise and like an idiot I agreed in September. And in came the higher acuity patients which 90% of them I can tell you belong at an LTACH not a SNF.

Here comes the good part. We work 8 hour shifts. On Monday the NP comes and you have to round with her on EVERY skilled resident and give her a rundown. That alone knocks an hour off your shift. If she gives you 75 orders, you have to put the orders in the computer and fax them to pharmacy, etc. Kiss another hour off your shift. Then you have to go to standup, and seeing as there are 172 residents in the building and every resident has to be reported on, that knocks another hour off your shift.

So you get to start off the work week trying to do the job of 2 nurses and 12 hours worth of work in 5 hours.

20 skilled residents means 20 complete sets of vital signs, 20 had to toe assessments which you have to document in the computer, 10 residents with fsbs who get ss insulin, we have a wound care nurse but she doesn't do any of the wound care she just rounds with the wound care doctors once a week on Wednesdays and they rip off everybody's dressing and take measurements (but don't replace the dressing). In fact you don't even know that the dressing is off until PT or OT says "Hey we just came to get Ms.Jones for therapy but her dressing was removed and she's lying on her side." You walk into the room and sure enough there the resident is with their a** in the air but because PT has a schedule too, you have to drop what you'really doing and do wound care. You have patients crashing left and right, one day I sent 3 skilled residents out and all were admitted to ICU. Wound vacs galore, TPN galore.

The day I told myself "enough is enough" I had 20 SNF residents and 20 LTC residents. Of the 20 skilled residents, 6 of them were hoyer lifts, 8 of them were 2 person transfers, 2 were getting TPN via PICC line and they needed lab work drawn and the results faxed to pharmacy, both of their PICC line dressings were due to be changed. One residents lab work came back and his creatinine was 4.62 (no history of kidney problems so he got sent out), I had 2 wound vacs dressings that needed to be changed, 3 people with stage 3 or higher decubs that needed their wet to dry dressings replaced, 10 on fsbs with ss insulin, 3 peg tube 2 of which were continuous, the other one was bolu feeding, 6 people on duonebs and it is corporate policy that you cannot leave the resident unattended while the duoneb is going, 3 of my LTC residents had fallen and were on neuro checks 2 of my LTC residents had MD appointments, my TPN arrived and I had nowhere to put it because our refrigerator was full of antibiotics. As I'm talking to the ADON about where to put the TPN, 2 admits roll through the door at the same time and my CMA shouted to me "Hey their rooms aren't even ready yet!" I yelled back "WTF do you want me to do about it?" And to top it all off neither our printer nor our fax machine worked at all that week so you had to go clear across the building every single time you needed to print or fax anything which you know is pretty frequently. For the last month my 8 hour days have become 11 hour days. I had a nervous breakdown and self terminated that weekend. Right now I'm on a mental health vacation. WTF is Healthcare coming to?

I overheard a CNA complaining about a nurse not toileting a resident when she was passing meds. Do CNA's not understand the time restraints nurses have?

Is this a problem at other facilities, too?? I have 25 residents that I am *supposed* to medicate within a 2 hour time frame. How could that even remotely be possible if I have to answer call lights and do all those vitals in the midst of a heavy med pass?? I am absolutely willing to answer lights after my med pass is finished, but I cannot spare the time while I'm passing meds. The majority of my 25 residents are difficult to medicate either because they don't want the meds or they have difficulty swallowing or they have a VERY large amount of various medications.

Also, as a nurse, I cannot leave just because my shift is over and if I'm not finished with everything 30 minutes after the end of my shift, management has a melt down about over time, but they also have a melt down if the nurse does not complete their charting.

Last week, I needed vitals for charting and the CNA did not do them. When she announced that her shift was over, I reminded her that I still needed the vitals completed (that she knew about when her shift started 8 hours earlier). She said nothing and left. So, I was chewed out for getting OT because I had to go get those vitals to finish my charting.

I feel like we are all adults and everyone knows their responsibilities. Why can't we all just fulfill the roles we were hired for??

Is this a struggle at other facilities, too?? And if so, how do you handle it??

I don't need advice on managing conflicts in the workplace. I need your verbatim scripts so I can articulate myself assertively and professionally. 

How would you: 

• tell a CNA you're moving them to a different hall.                                                                               

• confront a CNA who hides excessively during their shift, neglecting their duties and no where to be found.

• Shut down a bossy floor nurse for overstepping and trying to manage and mind your business for you.

PLEASE DON'T ADVISE TO SEND THEM HOME it's just not helpful what so ever. especially on night shift when we are already scheduled to be short staffed.

i'm starting my third week working in a skilled nursing facility on day shift as a new rn where i can have up to 30 residents. does anyone have a good "nursing brain" that they could share that would be good for writing down my residents & organizing my day? i am getting the hang of organizing my day & everything done but would like to have a nicely organized sheet where i can write everything down. anything would be greatly appreciated :)

(i've been working in ltc for the previous 3 years as a cna, so this environment isn't too new to me...)

I'm an LPN with over 14 years of experience in LTC, and I recently earned my BSN. I'm currently working toward my Master's in Nursing Education as well. I'll be turning 40 next month, and I'm at a crossroads in my career. I'm unsure if I should stay in LTC, where I feel comfortable and experienced, or if I should try transitioning into a hospital setting.

I've heard a lot of mixed reviews about working in hospitals, some horror stories that have left me feeling intimidated about whether I'll be able to adjust. The pace, the complexity, and the fast-paced environment are all things that make me second-guess whether I can handle it.

Has anyone here made a similar transition, especially after spending many years in LTC? How did you adjust, and what advice do you have for someone who's a bit nervous but ready to take the next step? I'd really appreciate any insights or experiences you can share!

Thanks in advance!

I'm hesitating to call the home cause I don't want to make any accusations until I know what the rules are. I know there must be some governing body that determines these things but I'm not sure what it is.

Thanks for any feedback!

Now I know how hard it is to stay awake overnight, but I don't think it's ok for staff to sleep while on duty. I've seen other CNAs bring in books, knitting, or puzzles to do in order to keep themselves busy so that they stay up. However, I was told by other midnight nurses that, technically, staff shouldn't be bringing in books, etc., to keep themselves busy because the staff shouldn't be "distracted" by these activities when they are supposed to be watching for call lights, changing residents, or whatever. Plus, I'm told that even on their 30-minute break, they can't go somewhere to sleep. (But they can leave the facility.) So what do you nurses do about this? What is your facility's policy about sleeping and bringing in things to keep staff awake? Sending the aid home? Suspension? Thanks in advance.

Should I just quit now?

And I start at a local hospital on the 16th of next month.

Is it the nature of the job (LTC duties)? Lack of variety? Do hospitals look view LTC experience as unfavorable experience?

I'm pretty new to the nursing world, but am learning that hospital jobs are highly sought after, while LTC facility jobs the ones to avoid. (Not necessarily my opinion, merely an observation.) Just looking for some insight/opinions!

I have to pass meds (and the time schedules of the meds are so crazy), start tube feedings, supervise CNAs, chart, pick up orders, check orders, treatments, and various other paper work that come in books.. and the worst of all is getting an admission.. i always fear that i'll get an admission .. and on top of all that, i JUST learned that i'm required to re-do the whole treatment book for the new month.. and my god, the daily interruptions i get.. supervisors coming every 5 mins to check the medex while i'm giving meds, CNAs calling me for this and that, residents not wanting to take their meds (i have to spend so much time just to encourage them to do so).

I don't want to quit because I want to be able to handle everything, and I've floated to every floor to know that other floors are easier to handle; still hard, but a little easier. I just don't believe one nurse can do it all safely.

1. Have you ever been attacked, physically or verbally by a patient or other non-nursing person (visitor, family member) on the job? Please describe the incident if you can.

2. Did your supervisor or DON offer you support or were you reprimanded?

3. What was the outcome? Was the patient given a psych consult? Any new orders written? Patient discharged or taken to ER for observation of increased altered mental status? Do you still take care of this patient? Did you sustain permanent and/or severe injury (and yes, if you suffered some post-traumatic stress, please let us know)?

Side note: Ok, I know there was a poll not long ago about nurses and nursing staff being assaulted or attacked at work, but can't find that thread for the life of me. If anyone knows where it is, please reply with a link. I really wanted to show a non-nursing person (which would be EVERYONE I don't work with!) how high that percentage of "yes" was. I believe it was over 90% of us that responded yes to having been assaulted in some manner at work, either by a patient or other party. As you all know, non-nurses have a very hard time understanding or believing exactly what we go through and the terrible things that we often consider "just part of the job". I have a hard time believing it myself. Maybe that shock is what keeps us there? Maybe learning that it happens (too often!) and is highly likely to happen dulls us and we forget how ridiculous it is that we nurses tolerate what would not be tolerated in any other job? Yes, we expect some of what happens, but is there not a line to be drawn stating "No more!" that we can sign? Even though we may expect certain behaviors and try our best to prevent them, it doesn't always work. When it does happen, why are we often blamed for the actions of confused, angry, demented, or under-the-influence patients? (these are musings, not the specific questions I'm asking, but feel free to comment or vent with me).

My question is directed in particular to the nurses and nursing staff at long-term care facilities, skilled nursing facilities, and those in direct patient care with confused and angry patients or residents. I am basically trying to get a picture of how high the percentage of attacks are in LTC/SNF (yes, because I work in that field, and yes, because I've been attacked and seen others attacked and have never seen management offer help or support of any kind, unfortunately). Other fields, please feel free to share your horror stories...I know psych and ER have a high percentage rate for getting smacked, spit on, kicked, punched, and so forth.:sstrs: