Is this a normal patient load for one nurse?

[Rivalicious]

I work as a LPN in a LTC facility for developmentally disabled men. I'm relatively new (2 months) and it's the first time working in a LTC environment so I don't have a lot of context, but I feel like my workload and responsibilities are excessive and putting myself and my patients in a situation that is unsafe.

There are 100 residents total at this facility. I work the overnight shift 6pm-6:30 although I rarely leave before 7. On a standard shift I work with one other nurse, and we each take 2 hallways-so I'm in charge of on average 48 patients.

There are varying degrees of acuity but since I'm usually stuck on the higher needs side I'll describe a typical shift there. Almosy all of my patients get HS meds, and about half get 5 or more. All are classified as severely disabled. About half are wheelchair bound, quite a few are blind, and 25% have major underlying health conditions like CHF, renal failure or cancer. Almost all of them have psychiatric co-morbidities- schizophrenia and intermittent explosive disorder, psychosis and major depression are the most common. Early onset Alzheimers is also very common. Lots of sensory issues and seizure disorders as well. 4 are on tube feeds. 5 are diabetic and need varying degrees of blood sugar monitoring. Many ostomies and caths, too many to count.

Since it's DD you can imagine it's tough to get a lot of these guys to take their meds. Many are spastic and have difficulty swallowing, so they need to be given tiny amounts at a time. Others are just uncooperative-they run away, get combative, spit them out, or throw them . Others require constant coaxing and coaching. I'd say about 40% fall into the category of being extremely difficult to get meds into.

There is never a shift that goes by without some kind of incident- whether it's a fight between residents, a fall, grand mals, or elopement. There have been several times I've been physically attacked and other nurses and care attendants have been seriously injured.

On a good night ill finish med pass by 11:30, although it's not uncommon to still be passing well after midnight. As soon as I finish the meds I have about half an hour to chart and then I start doing treatments. We have several that need pretty extensive dressing changes (pressure ulcers are unfortunately pretty common since so many are wheelchair bound, can't communicate pain, etc.) There are the tube feeds and flushes, BIPAPs and nebs, a few who have psoriasis or other skin conditions and need topicals.

I also need to get vitals most of the time because the facility doesn't hire CNA's- we do have care attendants but they have no real medical training and the turnover is ridiculous, so there are few who stick around long enough to learn skills like that. Because of the staffing issues it's not uncommon for me to have to change or clean a patient myself because if I don't they would sit there for hours in their own urine and feces. I've gotten to the point where I just empty the bags of my urostomy patients myself since at least once a shift one of them would overfill to the point of bursting and I'd have to change the entire setup. By the time I'm done with all this, usually around 3, it's time to start my 6am pass.

Oh, and we do in house hospice. Thankfully that isn't too common but when that happens, on top of everything I just described we are additionally responsible for pain control and end of life care for an actively dying person.

I feel like this is just too much work for one person and I'm starting to get burned out. Even with a 12 hour shift, on graveyard, I can barely get everything done. I chalk some of that up to me being new but in reality the other nurses who have been there longer, some even for years, don't fare any better. I don't have a moment of downtime during my shift, and I usually don't have enough time to finish charting. My manager is very understanding and I haven't ever gotten in trouble for this but I always leave there feeling like I have left so much work undone.

I know that I'm not the only nurse who has a heavy workload and to an extent that just comes with the territory, but at what point is it beyond what's acceptable? Am I risking my license by working here? We had the state come in recently and I know there were citations and fines, but I didn't hear any of the details.

I guess my question is does this within the realm of normal or is it time to find a new job?

[quickkarma, BSN]

Well, interestingly, I logged in to ask a similar question. I think this job of yours sounds exhausting and sounds like a heavy load to me. I've got day shift 1:15 ratio, sub acute TCU where the cart nurses handle all incoming phone calls during their med pass, along with all other nursing cares. After reading your post, mine doesn't seem so bad.

[Rivalicious]

I think part of the problem is my facility is licensed to be a residential center, similar to a group home, but the reality is it operates as more of a subacute facility. It's because the original resisent population (lots of guys have been living there since the 70's!) are aging, and experiencing the co-morbidities that come with it, plus the existing issues they had to begin with. When the facility opened the average lifespan of a DD person was very short-around 35 from what I've read. Now it's much longer, and there are a lot of medical and psych issues that are coming up which hadn't been prepared for.

I think we should be designated as at least sub-acute and have a patient ratio similar to yours (although I'm sure that is still high especially when you have other responsibilities dumped on you) but for whatever reason that isn't happening.

I'm sure 15:1 + phone duty on dayshift is no picnic either.

[Been there,done that, ASN, RN]

You work at a for profit facility that is milking insurance and medicare to maximize their $$$.

This is no longer about YOU.

In order to boost their bottom line, they are minimizing staffing, patient care and patient safety.

Stop enabling this, leave NOW and report to the state.

[Rivalicious]

You work at a for profit facility that is milking insurance and medicare to maximize their $$$.

This is no longer about YOU.

In order to boost their bottom line, they are minimizing staffing, patient care and patient safety.

Stop enabling this, leave NOW and report to the state.

OK, hold up though...it's not a for profit. It's a non-profit (run by monks actually) that has been in existence since the 70's. Maybe I'm niave but I'm pretty sure no one is getting rich here. The majority of their funding comes from fundraising and the administrators often pay for supplies out of their own pockets because insurance for DD is so bare bones. Not to mention they are salaried and regularly pull 100+ hours a week to keep the facility running.

I agree there is an issue with staffing ratios and safety, that's why I made the post, but the issure isnt one of a greedy corporation milking the system for a buck. If that was the case I would have been out the door already.

The issue is funding (state funds have been slashed) as well as poor management and high turnover. But the core staff there are genuinely good, dedicated people who love these guys and genuinely care about them. And the reality is, this is the only home many of these residents know- they have been here for 30+ years and have formed bonds with staff and other residents. They are particularly sensitive to changes in routine and would not be well served by the facility shutting down imo. But they DO deserve better care as an aging and increasingly Ill population. The problem is we don't get funded to support those needs, so I'm caught in a catch 22. I don't want to enable sub-par conditions or put my license at risk, but I genuinely care about the facility and the men who lI've there and want to help improve their lives in whatever small way I can.

[canoehead, BSN, RN]

A decent staffing mix would be an RN and two CNAs in my opinion. Not just one RN. The workload sounds too high, and the risk of injury when patients act out is pretty much 100%. Eventually you will be assaulted, and there won't be anyone to back you up. If they could keep a good MA for years, that's fine, but with the current turnover you need people that have skills on arrival.

[caffeinatednurse, BSN, RN]

That workload sounds insane. I work LTC and the ratio is usually 1:15 (short term rehab, skilled LTC unit) but can go as high as 1:27 (AL - but these guys are A&OX3-4 and usually stand at my cart for their meds before walking themselves to activities). Like the OP, I handle all incoming calls, deal with all falls, transfers, admissions etc. usually with 1-3 CNAs. If I'm lucky, there's an extra LPN on duty when SHTF. It's still manageable, though. Your situation sounds unsafe. I would find another place to be, pronto.

[4boysmama]

as someone who worked sub-acute/rehab, my very first question is WHY in the world are you doing dressings and treatments on nights? That stuff should all be done 7-3 or 3-11. It's absurd to be disrupting their sleep to do treatments.