Staff/Patient Ratio - 30 Patients per Nurse

  1. In my last job (which I quit due to inadequate staffing), I had 30 patients to take care of, 60 while the other nurse was at lunch. Our CNAs had 10 residents each, sometimes up to 20. The facility was a combination rehab/long-term-care facility. Approximately 1/3 of my residents were also Alzheimers and/or psychiatric residents. These residents required almost continual supervision. Even if I wanted to, there was no way I could do bedmaking, bedpans, etc. :uhoh21: Still, I did do these things when I had to - but that time cut into my required tasks as a nurse.

    The third floor of this facility has 60 beds, usually full. Evening shift (3-11) has only TWO nurses - that means each nurse must care for THIRTY residents all by herself. At night there is only ONE nurse caring for all SIXTY residents.

    The facility meets the hour/ratio requirements by hiring nurses in administrative positions - and counting any moving body with any type of direct care license (even if they aren't taking care of patients), making it seem like there are more nurses than there actually are. They count anyone licensed to do any type of direct care and who is in the building - regardless of the fact that some of those people are administrators, OT/PT/RT, or other staff that are not providing daily direct patient care.

    It is logistically IMPOSSIBLE for one nurse to provide competent, adequate, thorough, and truly compassionate nursing care to 30 residents. You can come in early, leave late, skip all meals and breaks, and still not do the things you should be doing, still not give the care the residents deserve.

    The formula used for nurse/patient ratios presents skewed results. Regulatory agencies should look directly at how many nurses are taking care of how many patients at any one time, not including staff that are not providing direct care at that time. I think New Hampshire's ratio is 3.7 hours, and HCFA says that a number below 3.5 hours is insufficient to provide adequate care. Cutting it close, aren't we? Recent recommondations are 4.1-4.6, I believe.

    Nurses on that floor, with 30 residents each: pass medications, do wound assessment and care, do treatments, catheters, resident assessments, incoming lab/radiology/consult results, call physicians to relay information and request orders, take new orders, enact those orders, stock, receive pharmacy deliveries, assist residents with ADLs, pass meal trays, feed residents, deal with resident family needs, requests for various assistance by residents and/or other staff, and deal with physicians. They answer the phones, monitor, assist, and supervise CNAs, and do a myriad of other tasks and miscellaneous resident care including but not limited to assessment, monitoring meeting social needs, performing treatments, and providing emergency care.

    There is no secretary, unit clerk, charge nurse, or other person to take care of phone calls/faxes/family/orders or the multitude of other tasks necessary behind the scenes (at the nurse's station). A nurse cannot be in the nurse's station, on the telephone, at a med cart, and in a resident room all at the same time!

    And of course this doesn't include all of the paperwork and documentation due at the end of the shift. No wonder staff turn over is high and residents receive inadequate care (carefully covered up by administrators and statistics).

    At the end of the day, it's the patient that receives inadequate care, it's the nurses that are exhausted, and it's the nurses license on the line should any legal liability result from the care she is unable to give due to inadequate staffing.

    Let's see any of the "adminstrators" who are also nurses work the floor for a week and do everything that they continually remind us to do. They can't. Because it's impossible.

    I know this for a fact. And I know for a fact that nurses and aides at that facility are signing off on care that they don't actually provide and tasks that they don't actually perform.

    30 patients to one nurse is WAY TOO MANY. 20 patients to one nurse is still too many. Hear it from the front lines - in LTC facilities, nurses should have no more than 15 residents - and in hospitals, no more than 5.

    Anyone who states otherwise has 1) never worked as a nurse or aide, 2) never been a resident or patient in an understaffed facility, and 3) is not living in reality.

    Oh - one final thought. The third floor of that facility, with 60 beds, has only ONE complete set of vital sign equipment! That is ONE tympanogram, ONE oximeter, ONE working BP cuff, NO large or small cuffs, and few if any functioning stethoscopes. No pen lights for neuro checks. No sharps containers in rooms. Only one hand sanitizer dispenser on each hall. In other words, it's BYOE (bring your own equipment). A long list of problems that made it difficult if not impossible to provide good care...
    Last edit by Colima on Apr 30, '06
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    About Colima

    Joined: Apr '06; Posts: 10; Likes: 41


  3. by   TazziRN
    Not 30, that's for sure!!! Not sure what the ratio is in CA for SNF's and rehab. We have a SNF in our building, I have a call in to the charge to ask her.
  4. by   mdfog10
    I believe that California nurse to patient ratios only cover acute- in patient hospitals.
  5. by   TazziRN
    Quote from mdfog10
    I believe that California nurse to patient ratios only cover acute- in patient hospitals.
    You're right, SNF just called me back. They have three LVN's to 44 residents.
  6. by   infectionRN
    Rehab/LTC facility in PGH, the ratio is the same 30-1. The difference being there is a charge nurse who handles pretty much all the docs calls, labs, family matters etc. 30-1 is crazy, I don't know how you are doing it, if someone crashes there goes your med pass and you are hours behind!!!!!!!!!! Talk about stress. Sure hope they pay you well, but then again is it worth your license and the stress that comes with it.
  7. by   suzanne4
    It can be 30 to 60 per nurse.
    CA does not have ratio laws for LTC/SNF. Only acute care facilities.

    This is the major reason that I think that it is absolutely ridiculous to place a new grad there or a foreign nurse. There are too many things to learn, and only minimal orientation. Have enver seen one give a full month of orientation. It just isn't going to happen.

    And for the foreign nurses, just the American idioms alone can cause many problems. Nursing in the US is quite different from most other countries.
  8. by   NurseyTee
    I just posted a similar reply about this same subject in another thread. I'm taking care of too many at a time too. I regularly have 30 or more by myself and it's killing me. Last week I had 52 by myself and thought I would die trying to get through that med pass. We lost 4 nurses last week due to this level of patient/nurse ratios. I have to do all the tx's by myself for all these pt's as well, not to mention charting. Needless to say, some days I just can't get all of it done. I concentrate on getting the med pass done first and foremost, and then the most crucial of treatments, and of course through all of this I have cont. tube feeds & tubing that need to be replaced. And never mind if you have someone crash on you or who might need to go out to the ER or if I need to get new orders from the Doc, then I'm waaaay behind. God forbid I go to the bathroom for a break in my 15 hours there. Ahhhhh.. I'm only ONE human being to cover FOUR wings. Why won't they hire more nurses???? I just don't get it. Pretty soon they are going to have ZERO nurses if they keep pushing us at this rate. What can we do? Is this just the way it is in LTC? I guess I need to go back to HHC.
  9. by   anndoodle
    This is EXACTLY why I quit working LTC. I was working the night shift, which should have 2 LPN's for each night. It never nurse would call in, and the 3-11 nurse would have to stay over until 1 or 2 am, then I would have to count out HER cart and be the only nurse in the facility (for 86 patients at that time...) until the next nurses came in at 6 am. I contacted the OLTC and they told me that in Arkansas, they can have 1 LPN for up to 80 residents. Yes...EIGHTY residents for one nurse to take care of all night long. But if there's 81 residents, they MUST have TWO nurses. I informed our administrator about this, and he stated to my face that "We only have to have 1 nurse for 120 residents....whoever told you that doesn't know what they're talking about". So, I quit.

    Now I'm happily working in geri/psych where I'm the med nurse for a maximum of 7 patients each day. *sigh of relief*

    It's amazing what really goes on in the nursing homes that the state isn't aware of, such as the staffing "fixes" mentioned above. Every nurse in the LTC facility where I used to work signed every one of the staffing sheets, but they NEVER worked on the floor.....just in their offices. 3 days out of 7, the treatment nurse wasn't there, and we were responsible for all the dressing changes, too. It was too much, and to this day, the turnover is still bad at that facility. They've even been bought by someone else recently and hopefully they are making some good changes. It's just amazing what gets under the state's "radar" sometimes. State enters the building, and those nurses ran like chickens with their heads cut off. If they did every day what they were supposed to do, then they shouldn't be concerned about state inspections. I wasn't....I did my job! But I wouldn't risk my license to be the only nurse, at night, for 86 residents anymore. PERIOD.
  10. by   dorimar
    insane. I absolutely would not do it and would not want to place a family memebee in any LTF obviously. HOSPITAL WORK! You are taking care of patients that the hospitals take care of as well just before they send them to you, and they are staffed much better.
  11. by   leslie :-D
    and the acuity level has risen dramatically.
    many of these residents are dnh's, so they're treated at the facility.
    i've known many hospital nurses that tried ltc and couldn't handle the stress and responsibility.
    people just don't have any idea.

  12. by   NurseyTee
    I truely love the residents and if they would make the ratio somewhere near reasonable I would stay, but I just can't take this. I'm looking for a new job tonight. I can't take this stress and it's a crying shame, because I was dedicated to staying with them for the rest of my career, but I can't at this rate, It will kill me. It's so not fair to the people that pay upwards of $85-90,000 a year just for room/board in this for profit place. It's beautiful, but they aren't getting what they bargained for, that's for sure.
  13. by   Colima
    Exactly. When regulators/auditors are expected, administration goes into overdrive, making it appear that they are meeting or exceeding recommendations/requirements. Suddenly there are continual activities for residents to participate in, whereas on "normal" days they sit in their rooms or in the halls with nothing to do. Aides are instructed to place water pitchers specifically reserved for "audits" in each room. Nurses are instructed to fabricate nursing notes missing in charts, including fabricating vital signs. Staffing is twice what it is on "normal" days. Auditors are carefully routed through the day and the facility, introduced to residents in private rooms and residents most likely to report positive things. It's completely dishonest. And then, when the audit is over, the administrators breathe a sigh of relief and the nurses and residents are left once again holding the bag. I not only quit, but I reported the situation to the Ombudsman and to local lawmakers. It was crazy. If one patient fell, suffered a stroke or other emergency, the other 29 - 59 residents were without medications and without nursing assistance for up to 3 hours at a time. And administrators would admonish nurses for not getting everything done, instead of realizing that it is their own policy and staffing levels, and ultimately the money issue, that results in things not getting done. I wonder if every nurse who works at an understaffed facility reported these conditions ... would something actually be done? I feel as if we are almost condoning things by not speaking out - or at least enabling it to continue.
  14. by   Nascar nurse
    Hi. Don't know that I have much to add to this topic and I do agree that there is a crisis in LTC, but it is not new. I started as a CNA in 1994, LPN by 1986 - worked all shifts - several years each, unit manager, staff development and currently an RN MDS co. These ratios have always been horrible. I was only 19 years old when I became an LPN and remember thinking that someone must have lost their mind to have me.. a 19 year old kid... in charge of 2 CNA's and 50 residents on 11-7 shift. My mother didn't think I could even take care of myself at that time[EVIL][/EVIL]. Unfortunately it really all goes back to the reimbursement level of our healthcare system, ie: medicare/medicaide. We are forced to take sicker and sicker residents that require very expensive medications and treatments and often we don't get fully reimbursed (thru the medicare PPS system). In my specific state, the state government spends more MEDICAID dollars per day on it's prisioners than it does on LTC reimbursement. Now that's pitiful! Also in my state, it is required that all LTC posts their daily staffing pattern in public view.. is it like this for all states? This only includes direct care staff, no managment nursing counted in this.

    Also, in case some of you weren't aware, you can go to then find nursing home compare. From there you can find staffing ratios for all your local LTC and compare yourself with them... You can even compare to state and national averages.

    And last but not least.. yes, nursing managment is often noted to be scrambling when state comes in and doing "things" they don't do everyday. This always got to me too, but now I do see the other side. It is really no different than any of you saying you can't always empty all the bedpans, do bedchanges and things like that because then you couldn't get your own job done. We all have a job to do and if we are doing someone else's job - than ours isn't getting done. We have many regulatory and coorporate obligations that we are required to meet (or else we won't have a job!). When state shows up, we have to refocus and prioritize too tho, just as you do when a resident falls and fractures hip right in the middle of medication pass and the med pass goes to the back burner for awhile. Really, I love the residents and wish I had more time for direct care... but direct care = late MDS's, which = no payment for the facility, which = very mad bosses, which = overtime (back to mad bosses), which = time away from my family, which = mad family... and now no one likes me . Sorry, I'll help when I see it's H_ll day, but otherwise I can't.

    Ok, guess I best be done now - didn't know I would get so carried away, sorry.