A Place for Mom: Staffing Concepts and the Role of the Nurse in Assisted Living

**VivaLasViejas**, ASN, RN

"It's a beautiful day in the neighborhood" might be the theme song in many assisted living communities, which are often organized into two or more 'neighborhoods' of 10 to 25 residents, depending on the building's layout and size. Each neighborhood has a resident assistant (RA) of some kind, either a CNA or lay caregiver, who is responsible for all of the residents in that section and assists them with ADLs, does their housekeeping and laundry, and sometimes even administers medications under the direction of a licensed nurse.

Other ALFs also have assigned RAs, plus medication assistants who pass all of the scheduled and PRN meds. One of the most controversial and hotly-debated issues in assisted living is the use of largely uneducated workers to give medications that, in some cases, can greatly harm residents if given unwisely or incorrectly. It can be argued that it takes licensed nurses two to four years to learn how to administer medications properly, yet corporations expect med aides (MAs) to be able to do it in 40 hours of training or less!

The trouble is, most companies that run ALFs do so on a shoestring. Since many charge residents hundreds, if not thousands of dollars less per month than the typical nursing facility, naturally the profit margin is going to be smaller......and nobody goes into business to barely scrape by. Thus, wages tend to be very low for the line staff, who in many cases are not required to be licensed or certified.

Unfortunately, the consumer often gets what he or she is willing to pay for, and ALF residents are no exception. Very few people want to work hard, be exposed to all sorts of bodily substances, and put up with fussy elderly people and hovercraft families who do nothing but pick and criticize.....especially for minimum wage. But the vast majority of those who do are compassionate and patient, and they do a great job for very little reward. It's when workers who lack education and understanding of human psychology are placed in a situation where they are asked to work beyond their competence that problems arise.

Here's where the nurse comes in.

An assisted living nurse, whether RN or LPN, is a little bit of everything. (For the sake of clarity, we'll call the nurse a "she".) To the powers that be, she's a huge expense (in many cases, nurses out-earn their administrators). To the staff, she's something of a school principal who is to be respected---at least on the surface---and perhaps even feared. To families, she is either a port in the storm or the one to blame when things go sideways with their Mom or Dad. But to the residents, she's a combination of healer, psychiatrist, confessor, health teacher, advocate, and boo-boo fixer extraordinaire.

The role of the nurse is another area where different states and different regulations create chaos. Some states mandate the presence of an LPN or RN in ALFs at all times of the day and night, while others permit them to employ a nurse for only a few hours a week to oversee delegated staff, who administer all of the medications including insulin and Lovenox injections, and perform treatments which may include wound dressing changes and catheter flushes.

Delegation, in the latter case, is the key. Only an RN may teach tasks of nursing care to unlicensed assistive personnel. She must also be able to identify proper candidates for delegation, supervise them at least periodically, evaluate them for continuing competence in these tasks; and if they cannot or will not perform the tasks correctly, she must rescind the delegation.

If this sounds scary, it should. Trust is a huge issue here,and not every nurse has the intestinal fortitude to place a brittle diabetic in the hands of a 22-year-old high-school dropout and allow her to give him sliding-scale insulin. But in assisted living, this happens every day.....and for the most part, with excellent results.

In the next article, we'll look at move-in criteria, where to look and what to look for when choosing an assisted living facility.

A Place for Mom: Staffing Concepts and the Role of the Nurse in Assisted Living

About VivaLasViejas, ASN, RN

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