How Do You Feel About This?

[LTCLVNinCA]

Hi Everyone,

First off this is my first post, but I have been a lurker for a long time. I just felt now would be a good time to ask you all a question. I apologize for its length...

I worked in a LTC facility. I enjoyed the residents and the type of work. This place is known for not being able to keep their nurses. I went to work there for my first nursing job right after passing the NCLEX (early January). I stayed until early April, and I left because something just didn't feel right about what they were leading me into.

I worked on PM's and during this shift, there would usually only be ONE nurse working the station. During AM's they have two nurses plus a ward clerk. The station (60 residents) is divided up between the two nurses and each nurse gets about 30 residents. During the PM's the nurse gets all 60 residents to herself. I was only left alone once, because I was a new grad and told them I was not comfortable handling all 60 residents by myself. However, they did tell me that within the month of April, I would be expected to handle the station myself. Therefore the majority of the time I was there I had 30 residents. Now, these are not alert and oriented residents. Most if not all are tube feeders, and only three of the 60 on the station are able to ambulate.

One night I was left alone after the other nurse working with me had to go home because her daughter was sick. I tried to find coverage for her, but no one would come in. I called my supervisor, and she bluntly told me "You are a nurse. Handle the station like a nurse. You do not need extra help. Step up." I did "handle the station" that night, but the next day I quit. It was way too much for me to handle by myself. I had two residents who were coughing up blood I had to send out to the hospital (never had to do that before, and I received little orientation on it). I had four falls, and two CNAs who were MIA. I tried to call the other floors for help, but they too were working with only one nurse to their stations.

Is this a normal ratio for LTC? Is it normal for a nurse to be left with 60 residents? I did get told by one of the day nurses that I needed to stick up for myself and make sure they always had someone else with me because "I would put my license in jeopardy" if I worked it alone.

I am in between a rock and a hard place it seems. I cannot find a job where I will be working AM's even though I need it. All of the offers I have been given are for PM's. I called my supervisor at this last place and asked if I could come back to work. She said yes. Now I am having second thoughts. I figured if I had to work PM's I would rather be in a place I already knew, than go through another orientation somewhere else. Does the ratio seem excessive to you? How do I juggle the needs of 60 different residents, plus the other duties I am to perform? I am wondering if I made a mistake by asking to come back. I know there are others out there who have much more experience than I do and that is why I am asking for advice. What would you do in my situation? I need a job (I am completely broke) but don't want to go somewhere I would be putting my license in jeopardy.

[TheCommuter, BSN, RN]

When I worked the 3pm to 11pm shift at a small nursing home, we had 60 patients always split between 2 nurses at all times. At the nursing home where I currently work, the patient census is 80 patients split between 4 nurses. Therefore, the nurses at my current workplace have only 20 patients each to care for during the PM shift. I live in Texas, which is very welcoming to LVNs. I attended LVN school in California, and there's a reason why I left 2 years ago...

Outrageous nurse/patient ratios are not uncommon in my area, but my state utilizes medication aides to alleviate the stress on the LTC nurse. For example, my friend worked at a facility where she had 52 patients on the 3pm to 11pm shift all by herself. However, a medication aide passed all of the oral meds to all 52 patients, so my friend was only left with nursing-related tasks (breathing treatments, injections, wound care, ostomies, blood sugars, charting).

60 patients on the graveyard shift is very reasonable, but 60 patients on the evening shift is rather dangerous, and should not be tolerated.

[Daytonite, BSN, RN]

while an assignment of 30 patients would be much better, it is not uncommon for charge nurses in nursing homes on the off shifts to have 50 and 60 patients. the other part of working in a nursing home that many don't realize is that you are more than a nurse. you are also a supervisor of the cnas as well as manager of all the patient care that needs to be done. this is a huge job. it requires being well organized. it is not enough to just know how to do the nursing. as you found, a patient who is ill and requires being sent out to the hospital requires a bunch of paperwork that needs to be done, phone calls to the doctor and family and documentation in the chart. this takes up time and has to be done immediately.

when you have that many patients to attend to, you have to be organized. you will spend most of your time getting tasks done and not much else. break down into a list who you have to do tube feedings with, who absolutely need treatments and medications that have to be done on time. they become your priorities. what i used to do was give medications to my tube feeders where i was giving intermittent tube feedings (like a can of a formula every 4 hours). i gave as many of my 5/6 pm meds during dinner time with the dinner food as possible, particularly to the patients who were up in the dining room--saves steps. some medications can be moved to the 10pm time slot if the 5pm med pass is too big.

the assignments to the cnas have to be done right at the beginning of the shift. i had assignments already figured out for whatever number of aides i was going to end up with. a fact of ltc is that cnas call off all the time and you are usually going to be left short-handed. just assume it is going to be the norm. i worked with my cnas and taught them to work smart. when they were working short i instructed them to do only the absolute things that needed to be done like incontinence checks and turning. sometimes i let them do rounds every 3 hours instead of every 2. if a shower or two get missed on a patient that is clean to begin with, it's not going to be the end of the world. their shower will get done on the next shower day.

something that you might not be aware of and that i didn't pick up from your post is that when you are running into situations that you are having trouble with or need guidance on how to handle, there is always supposed to be an administrator or a representative for the don on call. this person should always be known to you charge nurses. when you run into any kind of sticky situation this person should be called for advice and consultation. in the acute hospitals, a manager or supervisor is always available for this kind of consultation. and, the ca state law and medicare law mandates this for nursing homes as well. if at any time you feel that you are drowning so bad that you are going to be unable to complete your regular work, call this person and discuss that situation. it is far better to do that ahead of time, than go home leaving work undone only to come back and find out you have been written up for failure to do your work! your don should also be a source of advice as well. ask, "what do you recommend i do in order to get all this work completed when these kinds of situations come up?" or "how would you go about getting this all done when i'm side tracked by two patients that have to be sent out to the hospital?" that is part of the don's job, especially with a new grad who is inexperienced.

you can always post situations that occur and ask for advice here on allnurses. most of us who have worked in ltc have lived through just about anything you are about to encounter. what i can tell you is that i have been a hospital rn for most of my career and worked in ltc a lot as well, mostly to earn extra money. ltc was, without a doubt, the most challenging because it required very good organization skill as well as interpersonal skills (to deal with all the problems with the cnas). you are often alone in the facility and when you are new to it that is a scary situation. time and experience will take care of that. you have my best wishes. you are not alone. hang in there. it can only get better as you get more experience.

[wefdm21]

I'm sorry, but I don't care how common this is. It may very well be the norm in all 50 states. That still doesn't make it okay. Nothing else is at stake here except for the safety of the residents and YOUR license. I've done my 8 months in LTC and have finally been offered a job in another field. I will miss my residents, but I'm sorry, what these places are doing just to fill their pockets is wrong. The residents in my facility pay 6000-7000 dollars a month (or medicaid/medicare does, but still), and you mean to tell me you can't employ another nurse to work a 60 resident unit with me. I don't care what shift it is. Let's not mention that there's only 2 CNA's with 30 resident's each! You're crazy if you think these people are going to recieve quality care. I hope your facility is truely an exception, and this system is actually working for them. What finally took the cake for me is when one of my residents with bipolar disease who is allowed out side the facility at all times of the night threatened to wheel him self out onto the high way in his wheel chair. You cannot be everywhere at all times. 60 residents are just too many. Maybe if you had 60 perfect angels who slept all night and never put on a call light or attempted to get oob un assisted. Or there were'nt any crazy narc addicts who come to the nurses station to curse and threaten you nightly because you won't administer pain meds when they aren't ordered. Or in addition to your medicare charting and skin assessments and pertinent issues your facility doesn't make up some "night-shift chart audit project" or some other assignment for you to do. Then MAYBE just MAYBE. I'm sorry this is just my own rant. I say get your experience and get out.

[pagandeva2000, LPN]

I, also, do not wish to settle for the 'norms' of one nurse to 50-60 clients. It is not quality nursing that is being provided, under no circumstances. That is negligent nursing. Almost all nurses I know that have done this have shorted clients of medications and treatments; lied on their notes to protect themselves or have gotten in serious trouble. No nursing homes for me...

[NickiLaughs, ADN, BSN, RN]

I agree that it's crap.

I worked in a nursing home 5 months, and quit. I had it easy compared to you all also. I had 38 patients on evening shift. 2 CNA's usually, (was supposed to be three).

I had to pass 3pm meds, 5 & 6pm meds and 9pm (the longest) med pass. Most of my patients took 7-9 meds, 10 diabetics, 7 g-tubes and I had 6 combative patients. That didn't count all the dressing changes the day shift nurse skipped, so I had to do her dressings. (The DON was aware, she didn't do anything)

I always thought most of my patients were not cared for the way they should be. I couldn't sleep at night thinking of them, worrying about them. I got fed up, quit. And I will NEVER work in a nursing home until they start to fix this horrible problem.

I'm sorry, but a nurse should not be subjected to that many needy patients in a shift by herself with so little help.

[pagandeva2000, LPN]

I posted this story in response to a thread similar to this some time back, but, I'll bring it up again. I had a co-worker that told me she started working at a nursing home through an agency where her assignment was on an Alzheimer's unit. Most of the patients did not have ID bands, no pictures in the MAR. She told me that she had to do med passes for over 50 patients on the day tour and was still giving 8:00 am meds at 4:30pm. She asked the RN what she should do and the answer was "Do what you have to do". My co-worker told me that she flushed the medications she could not administer down the toilet, threw away the narcartics that she could not give, signed for all of the meds and then left for the day. She stayed a little while longer on nights and from there, she left to 'parts unknown' (my hospital). Now, what she did was not ethical, she knows it, but I could not blame her. I have to admit the cold fact that I would have probably done the same thing and got on the first thing smoking out of there. After hearing that particular story and many others, I made the decision that nursing homes would not be for me. It is a shame that our elderly may be subjected to this in their last golden years. It also let me know that many a nurse, whether she may be compassionate or incompetent may have done the same thing every now and then just to survive.

When I was a CNA, two things stand out in my mind. One was where an LPN asked me to give someone medications. It was 2:00 pm and she was still giving out morning meds. Of course, I said 'no', but I couldn't really blame her. I had an LPN friend that came and started working there, and at the end of our shift, he had a bunch of pills in his pocket that he flushed down the toilet because he just couldn't do it. Too many patients that could not swallow; had over 45 medications to pass and he couldn't hack it.

I have not been in such a situation before, however, I cannot honestly say that this would not be me if I were in such a situation; therefore, I decided to avoid places like that because I wish to be a consciensous and trustworthy nurse. But, thank goodness, I do have choices and am working in a hospital. We have our own issues, believe me, but having more than 15 patients to give meds is really unheard of where I work. The pay is lower, but sometimes, after reading things like this, I am almost grateful; even though this place gets on my last nerve.

[catslave]

I would never assume responsibility for 60 residents no matter the shift or CNA to resident ratio. I value my hard earned license.

The floor I work employs 3 nurses on the morning and afternoon shifts for their 66 residents with 2 nurses on the graveyard shift. Occasionally when census is low 2 nurses work the floor on am and afternoon shift. If a nurse calls out on the am shift, the unit managers will split a hall and there is always an on call manager for the other shifts who comes in if coverage cannot be found.

Quite frankly, I feel caring for 22 residents can be borderline hellacious depending on the level of care required.

[SuesquatchRN, BSN, RN]

That's an unsafe ratio, particularly given the level of skilled care required

[SuesquatchRN, BSN, RN]

That's an unsafe ratio, particularly given the level of skilled care required by these particular patients.

You did right to leave.

[jelorde37]

hmmmm. 60 patients on a pm shift? i dont think so. that is way too many meds, accuchecks, wound tx, and just stuff to do. at the facility that i work at, the nurse in ltc would get 60 patients. i worked that area acouple times and it was okay. bu then again, its NOC and not PM. i think 60 to 1 on a pm shift is way too crazy. good luck.